For use with patients 2-4 years old - Asthma Action Plan

ACE STUDY

Asthma Comparative

Effectiveness

Shared Decision

Making (SDM) Materials

For use with patients

2-4 years old

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• Half Day Clinic Flow

• Spirometry Technique

• Documentation Template

• Initial Script

• Follow Up Script

• Form 1: Patient Information Sheet

• Form 1: Follow Up Patient Information Sheet

• Controller/Reliever Posters

• Form 2: Blank Control Dial

• Form 3: Treatment Goals and Medication Preferences

• Form 4: Facts About Asthma

• Form 5: Allergy Information

• Form 6: Smoking Cessation Information

• Form 7: Severity and Control Dials

• Form 8: Medication Options

• Form 9: Medication Planner

• Form 10: General Types of Asthma Medications

• Form 11: How to Use Your Inhaler Handouts

• Form 12: Asthma Diary

• Prior Authorization Forms

TABLE OF CONTENTS

ACE STUDY

ASTHMA HALF DAY CLINIC FLOW • Registration

� Check patient in at front desk and collect co-pay if applicable

• Nurse � Bring patient back to exam room � On “ambulatory intake form” enter chief complaint as “asthma shared decision making visit” � Update pharmacy information � Obtain vital signs and document them

� Weight � Height � Blood pressure � Heart rate � Respiratory rate � Temperature � Pulse ox (if short of breath or having difficulty breathing)

� Update tobacco use and exposed under “social habits” � Measure peak flow

� Chart best of 3 � Instruct patient how to test at home � Give patient peak flow meter

� Perform spirometry � Test 3 times, more if necessary � Print results for Health Coach and Provider to review

• Health Coach � Describe shared decision making approach � Complete Patient Information Sheet � Determine current understanding of asthma � Review what asthma is and how it is treated � Confirm comprehension of information � Identify treatment goals � Review spirometry results � Determine current asthma severity level � Work with patient to define medication preferences � Discuss regimen options � Negotiate a decision about treatment � Complete “Documentation Template” for Provider

• Provider � Perform physical examination � Teach back to confirm patient understands new treatment plan � Update asthma health maintenance in EMR � Write prescriptions � Review proper inhaler technique � Complete and give asthma action plan � Give asthma diary � Type up and give discharge instructions

• Check Out � Set up follow-up appointment in 1 month

SPIROMETRY

PROPER TECHNIQUE

� Enter patient information into device

� Have patient loosen tight clothing, remove dentures or gum, and relax

� Have patient stand up next to the exam table

� Explain that the purpose of the test is to see how much air a person’s lungs can hold and how quickly that air can

be expelled with forceful effort

� Demonstrate the maneuver for the patient

� First ask patient to blow all air out of their lungs (exhale completely)

� Then have patient take the deepest breath in, filling their lungs completely

� They should feel like their lungs are balloons filled so full they might pop

� Tell patient to place the mouthpiece just inside their mouth between their teeth and seal their lips tightly around

it to prevent air from leaking out

� Encourage patient to exhale as hard, fast, and long as they can

� Tell them to “blast” the air out

� For at least 6 seconds in adults and 3 seconds in children – the device will beep when it’s time to stop

� They should try to force as much air as possible out in the first second then keep exhaling until every last

air molecule has escaped

� Tell patient to “keep going” or “keep blowing” until their lungs are completely empty

� Have the patient rest for a few seconds until they feel ready to repeat the test

� Perform the test 3 times

� Test may need to be repeated for poor effort (often times machine will indicate this)

� Examples: if patient coughs, laughs, breaths in, or does not exhale for the full period of time

� Print the results

� Look at the flow-volume curve (top)

� The curve should be relatively smooth without significant “bumps” (these signify inhalations) – repeat if

needed

� Look at the flow-time curve (bottom)

� The curve should go to at least 6 seconds for adults and 3 seconds in children – repeat if needed

SPIROMETRY

PROGRAMMING INSTRUMENT

� Press and hold down the On/Off button for 2 seconds until you hear a beep and the screen lights up

� On the Main screen, Perform Test is automatically highlighted - click Enter to select

� On the Select Test screen, New is automatically highlighted - click Enter to select

� On the Enter Patient Data screen:

� For ID, enter patient’s MRN (ex: 12345678) - click Enter

� For Name, enter patient’s first and last name (use 0,ESC for the space, ex: John Smith) - click Enter

� For Age, enter the patient’s age in years (ex: 22) - click Enter

� For Height, enter number of feet then use the right arrow key (>) to move over to enter the number

of inches (ex: 5 > 5 for 5 feet and 5 inches) - click Enter

� For Weight, enter the number of pounds with 3 digits (ex: 075 or 180) - click Enter

� For Ethnicity, use the arrow keys to scroll between the options (Caucasian/Hispanic/Asian/

Other/African) until the correct one is highlighted - click Enter to select

� For Gender, use the arrow keys to scroll between the options (Male/Female) until the correct one is

highlighted - click Enter to select

� For Smoke, use the arrow keys to scroll between the options (No/Former/Yes) until the correct

one is highlighted - click Enter to select

� For Asthma, use the arrow keys to scroll between the options (No/Possible/Yes) until the correct

one is highlighted - click Enter to select

� On the Test screen, FVC (Expiratory) is automatically highlighted - click Enter to select

� On the Baseline Setting screen, insert the bottom of the spirette into the tube by lining up the arrows. Be

sure to push the spirette all the way in and keep the plastic wrapper around the mouthpiece to block it

until prompted to “blast out” - click Enter for Next

� If an Error Message appears, check the spirette insertion - click Enter for OK

� To go to a previous field, press and hold the 0,ESC button

� Left arrow (<) deletes the last character, scrolls to the left or up

� Right arrow (>) scrolls to the right or down

� Proceed to perform 3 tests (see proper technique)

� After obtaining 3 tests, pull out spirette and click Enter on Print, then place spirometer on dock to print report

ACE Study

Provider Documentation Template

SUBJECTIVE: Patient presents for an asthma shared decision making visit. Asthma treatment goals and preferences established through shared decision making by Health Coach, ___________. Patient information form reviewed. See scanned document for complete details. Patient’s perceived level of control: � Well controlled � Moderately well controlled � Poorly controlled � Very poorly controlled

Patient’s asthma treatment goals: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Patient’s ranked preferences regarding treatment options: _____ Control _____ Side effects _____ Cost _____ Convenience _____ Other

OBJECTIVE: Physical Examination Best Peak Flow: _____ Age-Predicted: _____ Green Zone (>80%): _____ Yellow Zone (60-80%): _____ to _____ Red Zone (<60%): _____ Spirometry results: FEV1: _____ FCV: _____ FEV1/FVC: _____

ASSESSMENT/PLAN: Patient’s severity level (for patient NOT on controller medicine): � Mild intermittent � Mild persistent � Moderate persistent � Severe persistent Patient’s actual level of control (for patients on controller medicine): � Well controlled � Not well controlled � Very poorly controlled Shared decision making medication selection: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Proper inhaler technique review. Patient demonstrated competence. Treatment plan teach-back provided. Asthma Action Plan updated and reviewed with patient. Asthma diary given. Patient to follow-up in 1 month to reassess.

ACE Study SDM Pediatric Script Page

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Asthma Comparative

Effectiveness

ACE STUDY

ASTHMA COMPARATIVE EFFECTIVENESS

(ACE) STUDY

PEDIATRIC SCRIPT

Health Coach Protocol, Health Coach Resources, and Patient Handouts

These materials may not be distributed, used, or adapted without

written permission of the ACE Study Principal Investigators, Carolinas HealthCare System and the grantee institutions.


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Preparing for ACE STUDY Session

� Materials Needed:

o Patient medical chart REVIEWED PRIOR to session o Baseline spirometry results o Shared Decision Making binder for specific age

� Other Materials: o Asthma bronchial model and inhaler examples o “Taming the Wild Wheezes” book, opened to pages 2 and 3 o Electronic Medical Record (EMR), opened to patient’s chart

� Health Coach Resources and Patient Handouts: o Form #1: Patient Information Form o Form #2: How Well Controlled Is Your Asthma? (blank dial) o Form #3: Asthma Treatment Goals and Medications Preferences o Form #4: Facts About Asthma and Asthma Medications Handouts o Form #5: Learning About Allergies o Form #6: Smoking Cessation Resources; “Smoking and Asthma Don’t Mix”

Handout o Form #7: How Severe or Well Controlled Is Your Asthma (dial with symptoms and

lung function) o Form #8: Medication Options to Control Asthma Chart (for specific age and

insurance types) o Form #9: Medication Planner o Form #10: General Types of Asthma Medications o Form #11: How to Use Your Inhaler o Form #12: One Week Asthma Diary o Asthma Controllers/Relievers Posters o Asthma Action Plan (EMR, website, or paper form)


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Set the Stage � Establish rapport � Describe shared decision making approach

Provide Information (Health Coach and/or Group Visit) � Determine current understanding of asthma by child and parent � Review what asthma is and how it is treated � Confirm comprehension of information by both child and parent

Negotiation (Health Coach) � Summarize child and parent goals and information � Review spirometry results with child and parent � Provide assessment of child’s current symptom control and

treatment level in patients on a controller � Determine current asthma severity level in patients not on a

controller � Work with parent and child to define medication preferences � Discuss regimen options

Wrap Up (PCP) � Physical examination � Teach back � Update Asthma Health Maintenance in the EMR � Write/Fax prescription(s) � Review proper inhaler technique � Give asthma action plan and diary � Set up follow up appointment for one month

Gather Patient Information � Asthma symptoms and perceptions of control � Medication use � Alternative treatments used � Environmental triggers � Identify patient goals (Child, Parent, and Consensus)

Flow chart and process objectives for ACE STUDY


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SET THE STAGE: Health coach

� Establish Rapport � Describe shared decision making approach

� Hello, [child] and [parent]. I’m [your name]. Thank you for coming today. I’ve been looking forward to our meeting.

[Name of child], your asthma symptoms are significant enough for us to think there might be some things that can be done to improve them. I’d like for you to think of this as an opportunity to take a fresh look at how to take care of your asthma. In the past, your health care providers might have asked you questions about your asthma, examined you, and then said, “This is what your problem is, and this is the medicine you need to take. I’d like to see you again in a month to see how you are doing.”

We’ll approach your asthma care differently today. I would like for you and your parent to play a more active role than you both might be used to. Your breathing test, symptoms, and medical history tell us something about your asthma. But I’d also like you to tell me how your asthma is affecting your life and what you and your parent hope to get out of your treatment. I will be asking you both some questions about that today.

I’ll tell you the basic things we know about asthma and the different alternatives for treatment. Then we’ll all work together to help you and your parent choose a plan that will work best for you. To put it simply, I would like for us to SHARE the decision-making about your asthma care as equal partners. This is not easy for some people, including some health professionals, but I would like for us to try. If you are wondering what it means to be an “equal partner” in your asthma care, don’t worry - your role will become clearer as we go along.

Once we’ve made a decision about the best approach for you, whether it’s the same as what you are doing now or very different, your [doctor, nurse practitioner, physician assistant] will write it up as an Asthma Action Plan.

If you follow it as carefully as you can and you and/or your parent record your symptoms and the medications you take in an Asthma Diary, we’ll be able to see how well the plan is meeting the goals we’ve all set. And when we meet again in a month or so, we can make changes if you aren’t happy yet. How does that sound?

� Is there anything else either of you (parent/child) would like to get from this session? If yes, restate and note the child’s and/or parent’s additional goals. If goals are highly unrealistic, indicate that you will talk more about this during the session and the possibilities for improvement.


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� Do you have any questions for me now? Answer if question is straight-forward and/or indicate that this will be discussed in further detail in this or the next session. Gather PATIENT information: Health coach

� Asthma symptoms anD perceptions of control � medication use � alternative treatments used � environmental triggers

� Let’s start with some general questions about your asthma.

� Complete Form #1: Patient Information Form. Ask ALL questions and any “probe” questions to clarify or give detail to patient answers.

You will use Form #2: How Well Controlled is your Asthma? during this process.

You will also need to provide Form #5: Learning About Allergies for children with significant allergy responses. Additionally, you will need to provide Form #6: Smoking Cessation Resources and Smoking and Asthma Don’t Mix Handout to patients who are (or are suspected to be) smokers and/or smoking parents of asthmatic children. These resources should also be given to all children/teenagers that are in middle and high school and therefore likely exposed to peer pressure.

Note that a parent and/or child may give you information that is clearly based on a misunderstanding of asthma or asthma medications, or that indicates that he/she is engaging in behavior related to his/her asthma management that is incorrect or potentially harmful. If this occurs, it is acceptable to provide the necessary information or clarification at that time, including information that you would otherwise present during the “Provide Information” portion of the session. If you do this, be sure to quickly re-summarize that information again during the “Provide Information” portion of the script. � Identify Patient goals After completing Form #1: Patient Information Form, continue as follows:

� Given everything you have told me, what would you say are your primary goals for your asthma treatment - what do you want your asthma treatment to do for you? I’d like both you and your parent to tell me your goals.

� Complete the top of Form #3: Asthma Treatment Goals section.


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Try to elicit specific, personally meaningful goals from the child (for example, types of activities child would like to be able to do) and the parent. If child’s and/or parent’s goal(s) is/are apparent from what they have already told you, state what you believe is/are their goal(s), and allow the parent and/or child to confirm this or make modifications/additions. For example, you might say the following:

� From what you have both been telling me, it seems that the primary goal for [child’s name]’s asthma care would be to ______________. Would that be correct? Is there anything else that you want the treatment to do for you? If the child’s/parent’s goal is extremely unrealistic (such as “I want to get rid of the symptoms, but I don’t want to take medicines everyday”), prompt child/parent to explore goals that are more feasible, using statements such as the following:

� Yes, everyone wants that, but it may be very difficult with existing treatments. Although we can’t completely cure your asthma, we might be able to help you with some things that make it hard to live with.

It may be very hard to control your asthma without taking medicine every day, but we can talk about whether there might be changes at home or at school or in what kinds of medications you might take that would reduce the amount you need to take.

This is an opportunity to try to make some of the bad things about living with asthma better for you, so can you think of what you feel would be a big improvement - one that would be meaningful to you?

If the child’s and/or parent’s goal appears unnecessarily limited (for example, the child and/or parent appears to have accepted very poor control, severe activity limitations, or does not realize that better control is possible), inquire whether they would be interested in reducing their symptoms or the risk of asthma attacks, or whether they’d like to be able to do some particular thing they have given up. For example, you might say:

� Many people, especially if they have had asthma since they were very young, have gotten used to having symptoms or have given up on doing things they might like. However, with medications that are now available and better information on how to use them, most people can be free of symptoms most of the time and can lead an active life.

How would you feel about considering the possibility of making your symptoms better and being able to be more active? [If interested] We will talk about what medications might help you reach this goal and what you would need to do.


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Provide information: health coach

� Determine current understanding of asthma � Review what asthma is and how it is treated � Confirm comprehension of information

� Let’s talk for a few minutes about what asthma is.

[Child’s name], can you tell me what you know about asthma?

[If needed, prompt child:] How would you explain to someone who doesn’t have asthma what is happening in your lungs when you have an asthma attack? How might you explain what is different about the lungs of someone who has asthma?

� [Parent’s name], do you have anything to add to [child’s name]’s explanation of asthma? Listen to the child’s and parent’s explanations. Determine whether there is an understanding of asthma as a chronic problem and of the underlying mechanisms of bronchoconstriction and inflammation.

� Let’s look at these pictures and model of the lungs and see if it would help you explain asthma.

Show Form #4: What is Asthma? and There are 2 Types of Asthma Medications, as well as the airway model. Use these to explain what asthma is and how controller and reliever medications work in different ways to improve asthma. If needed, open the book “Taming the Wild Wheezes” to pages 2 and 3. Concentrate on points the child and/or parent misunderstands, as evidenced by their initial explanation. Misconceptions or unfounded concerns about side effects should be addressed, but without directly challenging the child and/or parent. Negotiation: health coach

� Summarize child/parent goals and information � Review spirometry results

� Now let’s begin to consider treatment possibilities for you. Let’s start with what you and your parent told me about your goals for your asthma care.

Summarize patient goals as stated on Form #3: Asthma Treatment Goals.

� Is there anything important missing?


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� Incorporate any additions or modifications that the parent or child mentions.

Begin the process of determining child’s asthma severity. Start by reintroducing Form #2: How Well Controlled Is Your Asthma? on which the child and/or parent indicated his/her perceived level of asthma symptom control.

� Earlier you used this meter to show me how well-controlled you think your asthma symptoms are. You and your parent felt that it was [well/moderately well/poorly/or very poorly] controlled.

Let’s look at what your spirometry results and symptoms tell us about your control.

Present and review the child’s spirometry results.

� FVC is the total volume of air you exhaled during the entire 6-10 seconds. FEV1 is the amount of air that you exhaled during the first second of that test. These values are shown as percentages of the average values for a child of your age and height.

How much air you can blow out in the first second, FEV1, tells us how much your airways are blocked by swelling and tightening muscles. Your FEV1 is high (over 80%) if you can blow a lot of the air out in the first second. However, the more your airways are blocked, the longer it takes to blow the air out because you are trying to force the air through a smaller passage. That is what it means if your FEV1 is low.

Discuss what the results mean in terms of amount of obstruction and potential for improvement. � Provide assessment of patient’s current symptom control and treatment level in patients on a controller

� OR Determine current asthma severity level in patients not on a controller

Turn to Form #7: How Severe is Your Asthma? (for patients NOT on a controller medication) or Form #7: How Well Controlled Is Your Asthma? (for patients on a controller medication).

� This handout has some guidelines that can be used to give a more specific indication of whether someone’s asthma is [mild/moderate/severe (for patients not on a controller medication)] or is well-controlled or not (for patients on a controller medication), based on symptoms and lung function. For example, well-controlled asthma (the green area) means that a person has:

� Symptoms < 2 days a week � Nighttime awakenings ≤ 2 times a month � No interference with normal activity � Albuterol use (rescue medicine) ≤ 2 days a week


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� Normal FEV1 between exacerbations � FEV1 > 80% predicted, FEV1/FVC normal � Exacerbations requiring oral steroids 0-1 times a year

Using these symptoms and lung function guidelines, in what category would you place yourself on this severity/control meter? [Have parent assist child with this.]

NOTE: If there is a discrepancy in the level of severity/control implied by symptoms versus lung function, you should use whichever criterion suggests a poorer level of control. You may apply clinical judgment if you suspect patient is a “poor perceiver” or is minimizing/denying perceived symptoms. Compare this level of control with child’s earlier estimate. If different, ask child to explain why they think their earlier estimate was different from the current estimate. For children NOT on a controller medication – use the severity classification on the dial [mild intermittent or mild/moderate/severe persistent] to determine which “Step” to consider initiating treatment. For children on a controller medication – identify the control level [well controlled, not well controlled, or very poorly controlled] to decide whether to maintain, step down, or step up therapy.

� Now let’s look at the various options that are used to treat asthma of this severity/control level and talk about ones that might enable you to meet your goals.

� Work with parent and child to define medication preferences

Show patient Form #8: Medication Options to Control Asthma. *Be sure to select the formulary that matches the child’s age and insurance type*

� Here is a list of asthma controller medications and the dosages usually used to treat mild, moderate, or severe asthma.

You can see that as a person’s asthma gets more severe (going from the yellow to the orange and red areas), more puffs are usually prescribed and the frequency of the inhaled medications may change to twice a day rather than once. [Point to an example]

Often, for more severe asthma, different medications are added that have different effects on swelling and tightening muscles. [Point to an example]

This is the full range of medications that are currently available to control asthma. Some of the medications and combinations give more control over swelling than do others. However, some combinations have other advantages.


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Return to Form #3: and refer to the bottom section listing Medication Preferences (typically cost, control, side effects, and convenience). Ask child AND parent to tell you what is most important to them. Later, they will work together to agree upon the most important medication preferences.

� We’ve listed your treatment goals. We know you and your parent want [goal] and [goal] and that you want/are concerned about [preference]. That suggests that you might be interested in medications that provide [some/moderate/very good/excellent] control over symptoms and inflammation and that you might be less happy with a medication that provided [more/less] control. (If control of symptoms/inflammation is part of patient’s goal, check “Control” box under “Preferences”)

[Parent], is paying for [child’s name]’s asthma medications a concern for you? [Or] You have mentioned that the cost of medications is a concern for you. I can suggest some generic options that will be more affordable. (If cost is a concern, check “Cost” box under “Preferences”)

We can talk about potential side effects, where there are any, as we consider specific medications. [If relevant] I know you are worried about [summarize any previously stated concerns]. (If child and/or parent have specific concerns, check “Side Effects” box under “Preferences”)

Convenience is really an individual matter. You can see that the medications on this list differ in how much they require you to do. Most are breathed in, but they come in different types of inhalers, and one is in a tablet form. [If relevant] You have said that it is important to you that [insert specific considerations regarding schedule, dosing, form of medication, type of inhaler, etc.] We will keep that in mind when we talk about specific medications and whether they will meet your needs. Now that we have identified what is most important to both of you in terms of the asthma medicine, I want for you two to come to an agreement on which things are most important. Then, I want you two to rank them from 1-5, with 1 being the most important goal for your asthma medicine.

� Discuss regimen options � Negotiate a decision about treatment with

� With those things in mind, let’s talk about which treatment options might meet you and your parent’s goals and preferences.

Your current medication(s) and the way you are taking it/them might end up being what you feel best meets your needs, but if we go over some other options, then at least you will know what else is available to choose from. Would that be OK with you?

Discuss specific options for child’s regimen, based on ASTHMA CONTROL/SEVERITY, TREATMENT GOALS, and MEDICATION PREFERENCES that are important to the child and parent. Do not rule out


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any options. You, the child, and the parent should consider regimens that are listed for the child’s severity level, but in some instances the child and/or parent may not accept any of these options as listed and you may have to negotiate options listed for a lower severity level than the child’s asthma. In these cases, the child and parent should be informed that such a regimen is unlikely to control the child’s asthma adequately. Some issues to consider in negotiation are: � Relevant co-morbidities and concomitant medications that may influence the choice of

asthma prescriptions. Ask for any necessary clarifications or additional information from child and/or parent.

� Chronic Rhinosinusitis: o If child scored 2 or more on chronic rhinosinusitis items asked on Form #1: Patient Information Form, incorporate negotiation of a prescription for a nasal steroid spray (Flonase, Nasonex) or antihistamine (Claritin, Zyrtec, Allegra) to take during the period between today’s session and the follow-up appointment. Recheck at the follow-up appointment to determine whether continued use is appropriate.

� GERD o If patient said yes to any of the 3 GERD items asked on Form #1: Patient Information Form, incorporate negotiation of a proton pump inhibitor (PPI - Prilosec, Prevacid, Nexium, Protonix) or H2 Blocker (Zantac, Pepcid).

� If child has had problems using specific asthma medications: o Avoid choosing a medication that has caused the child problems (e.g., past intolerance of Advair)

unless you have reason to suspect that reported problems with medication were not actually due to the medication or could be mitigated by specific measures to avoid side effects (e.g., spacer, rinsing mouth, reminder aids).

o If poor inhaler technique is an issue in terms of medication efficacy or side effects, assure child and parent that they will be taught how to use the device correctly or use a device/spacer and rinse mouth to minimize problems due to technique.

� Special consideration for discussing Singulair alone as routine controller: o Discussion of this regimen’s features (pros and cons) should include telling patients that those

who regularly take ONLY Singulair typically need to add an ICS when they have a URI. o Children who are just beginning a regimen of Singulair as their only controller

should be instructed that if a URI is accompanied by asthma symptoms, then adding an ICS will be needed. Those children’s parents should be instructed to call you if they have a URI, as soon as they begin to experience a worsening of asthma symptoms. You may need to add an ICS to their regimen at that time, but a standing prescription will not automatically be provided.

� For children who have used or are currently using Singulair as their only controller, you should investigate their previous history regarding URIs and their effects on the child’s asthma to determine whether they will need to add an ICS when they experience a URI.

o Negotiation should consider including an ICS on the Asthma Action Plan as part of treatment during URI for children for whom you believe it might be necessary.


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� Stepping up versus stepping down regimens: o This is a potentially useful point of negotiation with children and parents. Children/parents

whose primary goal is to get control of the child’s asthma may choose to begin treatment with a strong dose of medication and attempt to reduce the dose when their symptoms have been controlled. Children and/or parents who are hesitant or concerned about strong doses of medication may prefer to start with a lower dose and gradually step up to a level that adequately controls the child’s symptoms.

Select a medication regimen from the listed options to begin discussion with patient, considering child’s and parent’s expressed GOALS and PREFERENCES. Discuss the current regimen option with the child and parent using Form #9: Medication Planner.

� Form #9: Medication Planner: 1. Fill in current regimen and list important goals and preferences, writing in how the

regimen measures up on child’s/parent’s goals and preferences. 2. If current de facto regimen does not include regular use of any controller, the inadequate

control provided by this option must be mentioned (with the associated risks for a severe exacerbation) along with benefits the child/parent may see (e.g. low cost, convenience).

3. Children may be using, or want to consider using, a controller only during their “bad” seasons. The pros and cons of this option, which is not one of the standard recommendations, should be discussed. That the child and parent have been informed of these considerations must be documented on the child’s Asthma Action Plan if a non-recommended option is negotiated. Similarly, if the child and/or parent refuses for the child use any controller on a regular basis, that needs to be documented on the Asthma Action Plan.

� Write first new option on Form #9: Medication Planner. 1. Describe how the option meets their specific goals and preferences.

2. Highlight degree of control it affords (or limitations in this regard compared with other

options).

3. Mention other relevant features of the medication. With regard to cost, estimate cost to parent

of a 1-month supply based on their insurance status. Cost to the parent will primarily be

determined by their co-pay amount and the total number of different medications the child is

taking (including non-asthma medications). However, if child has a medication cap, then

consider whether the regimen will cause them to reach the cap before the year is over, taking

into account other regular medication use as well.

4. Incorporate reduction of environmental triggers as appropriate. If there is trigger/allergen


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exposure, discuss whether or not the child and parent could/would change exposure, and how

this might influence medication requirement.

5. Incorporate negotiation of spacer use if child currently does not use or uses one inconsistently.

Present a spacer as one way to avoid side effects (thrush) while simultaneously providing more

symptom control.

� Present a second option from the prescribing guidelines. If child/parent have goals or preferences that are not satisfied by the first option, then the second option presented should focus on the next most important preference that the child/parent identified. If the first option addressed the child’s/parent’s preferences but was not the option that provides optimal control, then it might be useful for the second option presented to be one step up from the first one in terms of control .

1. Write it down on Form #9: Medication Planner as Option #2

2. Start by contrasting this option with the first new option and the current regimen. How does it

differ?

3. Discuss level of control offered.

4. Discuss less important features last or omit if not relevant. Include estimated cost information.

5. Incorporate reduction of environmental triggers and/or spacer use as above.

� Present a third option. o If child and/or parent hesitates or does not seem satisfied with either of the first two, move on

to the next best-fitting option for their situation using prescribing guidelines.

o When all options have been laid out, revisit environmental control issues. If child and parent

will not make certain changes that could improve asthma control (e.g, cease smoking, give up a

pet), urge child and parent toward an option that offers greater control for the child.

o If child and parent are willing to make environmental changes that could reduce symptoms, then

they would be more justified in choosing a regimen that might offer less control but that is

better in terms of convenience, cost, and/or potential for side effects.

� Let’s take one last look at Form #3: Asthma Goals and Medications Preferences worksheet where we recorded your preferences. How well do you think this plan addresses your goals and preferences?

� We’ve decided that [child’s name] wants to try/continue taking ______________. We have gone

over all of the pluses and minuses of this plan. Do you [child and parent] feel you are satisfied and ready to give this a try? Do you have any questions about it?


14

***At this point, the child’s care will be transferred from the Health Coach to the Primary Care Provider. The Health Coach will need to complete all paperwork and give the forms to the PCP for review and documentation.*** WRAP UP: PCP

� Physical examination � Teach back � Write prescriptions

� Hello __________. Looking at your medication planner, could you tell me about what you and the health coach decided about your asthma treatment plan?

I am going to write you a prescription for _____________ (and __) that you can have filled today [or within 3 days if non-formulary medication is prescribed]. Here are some information sheets on these medications that you and your parent can take home with you. They may help if you have questions.

Give child or parent a copy of the relevant handouts from Form #10: General Types of Asthma Medications (i.e., those that correspond to their prescriptions). For all patients include:

1. The handout “How Long Will Your Canister Last?” 2. The handouts explaining the different types of asthma medications

� Give Asthma action plan

Provide an Asthma Action Plan to all patients, even if the child is going to continue on the same regimen and already has an action plan. This can be completed in paper format, through the electronic medical record, or online depending on clinic’s preference.

� I’ll also write this down on your personal Asthma Action Plan.

� 1. Write down the agreed-upon regimen in the “Green Zone.” 2. You may use your clinical judgment in deciding whether to instruct a patient to contact you if

(s)he experiences symptoms in the “Yellow Zone” of the action plan. 3. Consider prescribing (and include on action plan for “Red Zone” symptoms) a prescription for

an oral corticosteroid “burst.” i. For example - Prednisone (20 mg tablets) -take 40 mg (two 20 mg pills) for 5-10

days until symptoms are back to baseline for 48 hours. ii. If child uses a peak flow meter, then it can be incorporated into the description of

the action plan, but do not actively encourage or discourage peak flow meter use. You may use a peak flow meter during the session to help you later evaluate the efficacy of therapy if you choose.


15

4. When discussing “Red Zone” symptoms, instruct child and parent that if there is an escalation and persistence of symptoms listed (not just presence of those symptoms), the parent should call the child’s PCP or triage nurse, who will advise them on what actions to take. Children should go to the ER/urgent care or call 911 if they experience symptoms that include: (1) having trouble walking or talking due to shortness of breath, or (2) having lips or fingers turn blue or grey.

5. Check child’s and parent’s understanding of routine medication schedule and action plan.

� I’d like for you to pretend that I am a family member who wants to know what your asthma medication schedule is and what you would do if you have symptoms. Can you practice telling me what you would say? Include all the information - the medication name(s), the amount, and how often you take it. Make sure child can describe his/her action plan accurately. Coach until (s)he can state it correctly. If child is too young to describe treatment plan, have parent describe it to you. � Review proper inhaler technique

� It is also important to make sure that your inhaled medicine(s) really get(s) down into your lungs

where it/they will be the most effective in reducing your asthma symptoms.

If inhalers are not used correctly, the medications don’t help much because they can’t get all the way down into the narrow airways where your asthma happens. That is true for both your albuterol (quick relief medicine) and the inhaled controller medications.

If patient uses both an HFA and a DPI

� It can also be difficult for children using both types of inhalers - HFA’s and DPl’s -because the proper techniques for the two are different in ways that can be confusing.

Let’s take a minute before we finish here to review the correct way to use your inhaler(s).

Review and demonstrate proper inhaler technique for child using all relevant sheets from Form #11: How to Use Your Inhaler.

Then have child demonstrate technique. Coach until proper technique is achieved, using checklist on the last page of Form 11: How to Use Your Inhaler. If more than one type of inhaler is prescribed, highlight differences between the two as you review, demonstrate and coach. (Note: all patients should get demo of HFA for use of their albuterol inhaler) Give child and/or parent a copy of only the relevant handouts from Form #11: How to Use Your Inhaler (i.e., those that correspond to their prescriptions). All patients should receive an HFA inhaler use


16

� You might not see as much of a change in your symptoms as you would with a more intense plan, but this will help you to see how much improvement you get.

� You probably won’t see very much change right away, but if you are taking the medicine every day, you should begin noticing that your symptoms are getting a bit better within a couple of weeks.

If they have chosen a regimen with good control.

If they have chosen a regimen with less control.

handout. If appropriate to the child’s inhaler, prescribe a spacer and emphasize its effectiveness in delivering medication. The strength of the recommendation to use a spacer should be proportional to the strength of the medication(s) the child is taking because the potential for side effects (e.g. thrush) increases as medication strength increases. Provide all children/parents with information about proper cleaning of spacer. If child brought spacer, check its condition to determine whether a new one should be prescribed. � Give asthma Diary � Set up follow up appointment

� OK, this is our plan! You have a prescription(s) and we have reviewed your inhaler technique together, and you’ve agreed to try this medication for one month. Then we will meet again and talk about how things are going for you.

It is very important for you to really give this plan a chance to work. I’d like for you to keep track of your asthma symptoms from now until our next meeting. It can be very helpful to closely follow what is happening with your symptoms. Have you ever kept an Asthma Diary? Sometimes when we keep track of things carefully, we begin to see patterns that we didn’t notice before.

Show child and parent Form #12: One Week Asthma Diary and explain how to fill it out. Have child complete Day l row for the day preceding this session. Determine whether child understands how to complete the diary, and encourage parent to supervise these entries. Answer any questions. Give patient 4 copies.

� We can talk about what has happened and how you feel about it when you come back in a month for your follow-up appointment. If something doesn’t seem right or you have a question, please feel free to call me in between. I’d rather you called me than to wait and find out something hadn’t gone right. Does this sound OK?


17

How confident do you feel about being able to take this/these medications for the next month?

Affirm their choice if they don’t seem especially confident. Explore barriers and try to identify ways to overcome them. Assure them that they can change the plan if it is not working for them.

� When you check out, a follow-up appointment can be scheduled for 1 month from now.

� Indicate on discharge paperwork that follow-up appointment is to be scheduled in approximately 1 month.

� We will make copies of the forms we completed today, so that you and I can both have them. � Make photocopies of the following forms: (scan into EMR)

o Asthma goals/preferences o Medication planner o Asthma action plan

� Here are your copies of the forms and discharge papers. If you do have problems with

your asthma (if you get into the red zone on your action plan), you should follow the instructions on the Asthma Action Plan “Red Zone” regarding your medication use and contact me or the triage nurse. Of course, if the problem is severe, as the action plan indicates, you should seek urgent care or ER care, or call 911. Contact me afterward if you have had to go to urgent care or the ER for asthma. Is there anything else you would like to ask or discuss?

I would like to thank you for coming in today. I look forward to seeing you in one month.

ACE Study SDM Follow-Up Script 1

Asthma Comparative

Effectiveness

ACE STUDY

PEDIATRIC FOLLOW-UP SCRIPT

ASTHMA COMPARATIVE EFFECTIVENESS

(ACE) STUDY

These materials may not be distributed, used, or adapted without written permission of the ACE Study Principal Investigators, Carolinas HealthCare System and the grantee institutions.


Preparing for SDM Follow-Up Visit

Overview: • Introduction • Review Session 1, phone calls • Evaluation of regimen • Discussion/Negotiation of additional treatment options (as necessary) • Wrap Up

Materials Needed:

• Patient medical chart (REVIEW BEFORE SESSION) • Baseline spirometry results • Follow-Up Script • Patient’s Chart with Session 1 forms:

o Form #1: Patient Information Form (review before session) o Form #3: Asthma Treatment Goals/Medication Preferences worksheet o Form #9: Medication Planner worksheet o Asthma action plan

• Patient Information Form - Follow Up • Asthma Controllers/Relievers Posters • Form #8: Medication Options to Control Asthma Chart • Form #11: Checklist for Proper Inhaler Use/How to Use Your Inhaler • Form #12: One Week Asthma Diary (4 copies)

Follow-Up Session Scheduling Note: Follow-up sessions should occur approximately one month after Session 1. Occasionally a patient may be unable to schedule a visit at one-month due to travel or other reasons, or may fail to keep his/her follow-up appointment and you will have to reschedule the follow-up visit. You should make every attempt to complete the follow-up visits within six weeks of Session 1. However, in some cases, there may be patients for whom you have great difficulty doing so, despite several attempts.


Flow chart and process objectives for SDM Intervention Follow-Up Session

Introduction • Reminder of shared decision making approach • Summary of what will be covered in Follow-Up Session

Evaluation of regimen and current inhaler use • Evaluation of regimen and current inhaler use • Review Session 1 goals and treatment decision • Review content of any phone communication since Session 1 • Assess child’s adherence to regimen, including any reasons for nonadherence • Review of asthma diaries (i.e., recent asthma symptoms) • Elicit parent’s and child’s perceptions of regimen success • Re-assess inhaler technique

Discussion/negotiation of additional treatment options (as necessary) • Determine whether to initiate discussion of new treatment options • If no discussion is needed, skip to wrap up • If new discussion is needed: • Present new options

o Engage in negotiation o Make a decision about treatment regimen o If warranted, write new prescription, complete action plan. Give new medication handouts and

inhaler use handouts.

Wrap Up • Give all patients a new set of asthma diaries. • Encourage parents to call with questions when needed. • Schedule follow-up appointment in 1-6 months (depending on severity and level of control)


SDM Follow-Up Session Introduction Remind parent and child that sessions will be conducted using a shared decision making approach in which the parent, child, health coach, and PCP work together to find the best way to achieve the child’s and the parent’s treatment goals for the child’s asthma.

• Summarize what will be covered in the session

• Brief review of things discussed in Session 1 and in interim phone calls (if any)

• Evaluation of current regimen, using symptom diaries completed during last 4 weeks and asthma goals listed at Session 1

• Discussion and negotiation of additional treatment options, if necessary

• Discussion of plans for follow-up (in 1-6 months depending on severity and level of control)

Evaluation of regimen and current inhaler use • Briefly review with parent and child their stated treatment goals and medication preferences using Session l’s Form #3:

Asthma Treatment Goals and Medication Preferences worksheet. • Briefly review with parent and child the treatment decision that was made using Session 1 Form #9: Medication

Planner and the Asthma Action Plan. • Mention the content of any phone contacts that took place between Sessions 1 and 2, noting any changes made in regimen

or concerns addressed. • [Using Patient Information Form] Review with child and parent any asthma symptoms since Session 1 (approximately

one month ago). Use the child’s completed Asthma Symptom Diary (4 -1-week copies) to facilitate this conversation. Check the following:

o How often has child been experiencing asthma symptoms during the daytime? o How often has child been woken up at night by asthma symptoms? o How often has the child used a short-acting beta agonist inhaler (albuterol) for quick relief from asthma

symptoms? o Has patient gotten any medical care for asthma since the last time you spoke? If so, what was the reason? If

yes, was any treatment administered or any changes made in the patient’s asthma regimen? Ask parent AND child how well the regimen is meeting their stated goals and preferences, including both goals related and unrelated to symptom control that were not discussed above. Acknowledge the child’s experience - successes or problems. • Assess patient’s adherence to current regimen. Find out specifically what child has been taking (using Asthma

Controllers/Relievers Poster if necessary), on what schedule, and with what regularity. If child has not been adherent, probe both parent and child for reasons.

• If patient has had adherence problems, try to determine whether nonadherence is a CAUSE or CONSEQUENCE of any

expressed dissatisfaction with treatment outcomes. • If nonadherence seems to be a cause, explore barriers and try to find solutions. • If nonadherence seems to be a consequence of the treatment not having met the patient’s goals (i.e., the patient really

gave the regimen a chance to work), then consider whether parent and/or child wishes to consider some change in treatment.

• Re-assess child’s current inhaler technique, using Form #11: Checklist for Proper Inhaler Use/How to Use Your Inhaler. Have child demonstrate for all relevant inhalers. Coach and correct any errors. Provide parent or


child with new copy/copies of Inhaler Use handouts if child continues to need practice with technique, or no longer has original copies.

Discussion/negotiation of additional treatment options (as necessary)

• Determine whether to initiate discussion of new treatment options. Assess using the following questions:

1. Are the parent’s AND child’s goals and preferences being adequately met? 2. Have symptoms deteriorated or not improved such that discussion of a stronger regimen is warranted? 3. Do side effects need to be addressed? 4. Is there a reason to consider stepping down therapy? 5. Is there new information that might change the assessment of the child’s level of control, using Form #7: How Well

Controlled is Your Asthma? 6. Has patient modified his/her goals since Session 1? If so, complete a new, blank copy of Form# 3: Asthma

Treatment Goals and Medication Preferences worksheet.

• If no discussion negotiation is needed, skip to Wrap Up with the Primary Care Provider. • If new discussion/negotiation is needed:

1. Consult Session 1’s Form #9: Medication Planner worksheet. 2. As appropriate for addressing parent’s and child’s current concerns, revisit one or more of the treatment options that

were not chosen but are listed on the Medication Planner. 3. Use a new, blank copy of Form # 9: Medication Planner worksheet to write down any options considered at

Session 1 that are being reconsidered now. Once again, discuss options in terms of parent’s and child’s current goals and preferences. Compare and contrast with current regimen.

4. Add to the worksheet any new treatment options not discussed at Session 1 that may now be relevant for parent’s and child’s goals or preferences. Discuss option in terms of goals and preferences. Compare and contrast with other listed options and current regimen.

5. Engage parent and child in discussion of their preference for new regimen. 6. Establish specific agreement for medication use and how its success will be evaluated.

* At this point the patient’s care will be transferred from the Health Coach to the Primary Care Provider * • If parent and/or child has decided to try a new regimen:

1. Write a prescription for new regimen. 2. Complete and review new Asthma Action Plan. 3. Provide teach back to make sure child and/or parent can describe his/her plan accurately. 4. Provide patient with new Form #10: General Types of Asthma Medications, if different medications will be

used. 5. Provide patient with new Form #11: How to Use Your Inhaler if different types of inhalers will be used.

Wrap Up Give all patients 4 new copies of #Form 12: Asthma Diary sheets. For those continuing on their Session 1 regimen, urge them to continue tracking their symptoms for one more month. For those with a new regimen, explain that the diaries will help them determine how well the new regimen is working. Schedule follow-up appointment for patient in 1-6 months depending on their severity or level of control. Children now under good control may not need to be seen for 3-6 months. Those with severe persistent asthma under poor control will likely need to be seen again in 1 month.


• Make photocopies of the following forms: • Child’s completed diaries from Session 1 • New Form #3: Asthma Treatment Goals and Medication Preferences (if applicable) • New Form #9: Medication Planner (if applicable) • New Asthma Action Plan (if applicable)

o Give patient the originals of these forms. After patient leaves:

1. Add any copies of diaries, asthma goals worksheet, medication planner, and new action plan to patient’s chart. 2. Document all relevant information from the session in patient’s medical record.

Question Probe Notes

• How much does asthma get in the way of what you need and want to do every day?

� Activity level (Sports, Playing with friends)

� School and/or home life � Relationships with friends/family � How you see yourself � Anything else?

• Of the things you just mentioned, what bothers you the most or what would you most like to change?

• Parent, what concerns you most?

• How old were you when you were diagnosed with asthma?

• Years ____________


• In the past month, did your asthma wake you up at night (including asthma-related coughing)?

• [If yes] How often? • Awakened at night? � Y � N • Frequency or # of times? ___________

• In the past month, did you miss any normal activities because of your asthma? (school, sports, extracurriculars, etc.)

• [If yes] How often? • Missed daily activity? � Y � N • Frequency or # of times? ___________

• How often do you have episodes in which your asthma is especially bad (we call these asthma exacerbations, attacks, or flares)?

• Have you ever had to go to the ER or an urgent care during an asthma attack?

• [If yes] When was the last time?

• Have you been ever been in the hospital because of your asthma?

• [If yes] When was the last time? • Have you ever been intubated (had a breathing tube inserted)?

• Does your asthma make you cough? • [If yes] How often? • What is the cough like?

• We cannot cure asthma, but we can con-trol your symptoms with the right medica-tions (decrease coughing, wheezing, etc.)[To child] How well-controlled do you think your asthma symptoms are? Parent, how well-controlled do you think his/her asthma is?

• Can you two agree on how well-controlled your asthma is?

F O R M # 1: P E D I AT R I C I N F O R MAT I O N F O R M

Symptoms

Asthma Bother

ACE Study Form #1: Pt Info Form, Page 1 of 5

EMR Sticker

G O TO FORM #2: HOW WELL

CONTROLLED IS YOUR ASTHMA

A N D H AV E PATI E N T I N D I C AT E W H E R E

T H E Y T H I N K TH E I R C O N T ROL I S B Y

MOV I N G T H E A R ROW .

Form completed by: _____________________ Date: _____________


Y � N �

Y � N �

Y � N �

Y � N �

Y � N �

Y � N �

# Y ______

What are your CURRENT PRESCRIPTIONS for asthma?

(Have parent assist if necessary.) Let’s start with albuterol.

For each medication:

� How many puffs/pills are you supposed to take

each time?

� How often is it supposed to be taken?

� How many days did you take it last week?

� How many puffs/pills do you usually take?

� How do you and/or your parent think this medica-

tion works for your asthma?

� Med 1 _ALBUTEROL_ Rx: _______________

# days taken last week _________ Usual # of puffs ________

How child and/or parent thinks it works:___________

—————————————————————

� Med 2 ______________ Rx: _______________

# days taken last week _________

Usual # of puffs ________


—————————————————————

� Med 3 ______________ Rx: _______________



—————————————————————

� Med 4 ______________ Rx: _______________


Usual # of puffs ________


—————————————————————

Show me how you use your inhaler? [Examine technique using appropriate “Skills Checklist” on the last page. Note errors, but do no correct. Provider will review in detail and give patient handouts.]

Y � N �

Y � N �

Y � N �

# Y ______

Chronic rhinosinusitis:

• Do you have a stuffy, runny, or plugged nose for a lot of the year?

• Do you have itchy, watery eyes a lot?

• Do you have drainage in the back of your throat (post-nasal drip) most of the year?

• Has your health care provider told you that you have chronic sinus problems or allergies?

• When you have a cold, do your nasal symptoms (stuffy or runny nose) usually last for 3 months or more?

• Do you have trouble smelling things?

Gerd:

• Do you have a burning feeling in your throat sometimes after you eat (heartburn or indigestion)?

• Does food sometimes come up in the back of your throat (regurgitation)?

• In the past month, have you had coughing, wheezing, or shortness of breath that was not relieved by taking your rescue medication ?

Medication Use: show Asthma Controllers/Relievers posters

EMR Sticker


EMR Sticker


• Many people have a hard time taking their controller medication like their doctor told them to. [Point out what their controller medication is.]

• How often do you miss taking a dose of your controller medication(s)? [State name(s)]

• What makes you not take your medicine? [Examples: forgetting, being too tired or busy, deciding not to]

• Many people cut back on the amount of controller medication they take, or they don’t take it as often or in the amount their doctor prescribes.

• Have you or your parent decreased the amount of medicine you take? Why?

• What happened? • Did you continue taking a decreased amount or stop altogether?

• How did that work out?

• Have you tried taking more of your controller medications than what your doctor told you to take?

• What led you to do this? • What happened when you did it?

• What asthma medicines have you tried in the past that you didn’t think helped or had side effects?

• What happened when you took them? [Probe if reported problems are unlikely to be attributed to the medication]

• What did you do about that? • Did any other asthma medications give you problems?

• How do/would you feel about taking asthma controller medication every day? Parent, how do you feel about your child taking a controller medication every day?

• Are there any other things that might bother you about taking asthma medications every day?

• What are the worst things about

taking asthma medications every day?

• Do you think that taking controller medications every day would make

your asthma better?

• [If no] Why not?

• Are you concerned about side effects of any asthma medications?

• What are you concerned about? [Probe further if side effects men-tioned have not been documented]


• Have you ever tried anything other than prescription medications to help with your asthma? For example:

� Vitamins � Herbs � Acupuncture � Deep breathing yoga � Seeing a chiropractor � Anything else?

• [For each] Did it help your asthma?

• Do you think any of these things were helpful in reducing your asthma symptoms?

• [If no] Do you have any thoughts on why this didn't work for you?

• Did you add this/these treatments to your asthma medicines or did you try to use them instead of taking asthma medicine?


• Are there different times of the year that your asthma is better or worse?

• When is it worse? Worse at times? � Y � N When? ______________

• Are there certain things at home/school/outside that make your asthma worse?

• [If yes] Can you give an example?

• What changes have you and your family made at home to avoid your asthma symptoms? (Ex: Pillow Covers, Dehumidifier, No pets)

• Have those changes been helpful?

• Are there more changes you think you and your parents could make?

• What are they?

• What gets in the way of these

• Does anyone at home smoke? • [If yes] Have they tried to quit? • In [middle or high] school, there is often peer pressure to begin smoking tobacco and marijuana. Smoking is bad for everyone, but it is especially bad for you because you have asthma. Smoking can make your asthma much worse and can lead to more asthma attacks and hospitalizations. I’m giving you some resources so you understand more about how hard it is to quit smoking and how bad it is for your asthma.

� Check box indicating that you have recommended cessation for smokers and provided handout resource “Smoking and Asthma Don’t Mix.”


Alternative Treatments

environmental triggers

EMR Sticker

If necessary for this section, show pictures on the Asthma Controllers/Relievers Poster

Form #1: Pediatric Information Form - follow up Session

ACE Study Form #1: P.I. Follow Up Form Page 1 of 1

� How often have you experienced asthma symptoms during the

daytime?

� How often have you been woken up at night by your asthma symptoms?

� How often have you used your rescue medicine (albuterol) for

quick relief from your asthma symptoms? (NOTE: If patient

has brought back asthma diaries, refer to diary information

when discussing this with a patient.) � Have you had any other medical care for asthma since the last

time you saw me? [If yes] What was the reason?

� [If applicable] Did they give you any medicine or change the

asthma medicines you and I chose together? � How do you feel about your current symptoms, or changes in

your symptoms, since I last saw you in our special asthma visit?

Is/are the medicine(s) we chose meeting the goals and

preferences you told me about? (Acknowledge patient’s

experience - successes or problems)

Question/Diary Review Notes on Patient Responses/Diary Data

What controller medications have you been taking since you last saw me? (NOTE: Again, if patient has brought asthma diaries, refer to diary information when discussing this with the patient.) For each medication: � How much do you take (dose) and when do you take it? � How many days in a week did you take ________ on this

schedule? [If patient has not been adherent] What has kept you from taking

your ________ as prescribed?

If non-adherence seems to be causing dissatisfaction with

outcomes, explore barriers to adherence and try to find solutions.

If patient has had adherence problems, try to determine whether

non-adherence is a CAUSE or CONSEQUENCE of any expressed dissatisfaction with treatment outcomes.

(If non-adherence seems to be a consequence of unsatisfactory

treatment results (i.e., the patient really gave the regimen a chance

to work), then consider whether a change in regimen is indicated.

� Med 1 ALBUTEROL Rx: __________________


Usual # of puffs ________ How parent/child thinks it works: ________________

� Med 2 ______________ Rx: _______________


Usual # of puffs ________ How parent/child thinks it works: ________________

� Med 3 ______________ Rx: _______________


How parent/child thinks it works: ________________

� Med 4 ______________ Rx: _______________


How parent/child thinks it works: ________________

EMR Sticker

MEDICAMENTOS DE ALIVIO

Generic Albuterol

ProAir HFA

Ventolin HFA

Proventil HFA

Xopenex HFA

Xopenex Nebulizer Solution

Albuterol Nebulizer Solution

Singulair

Symbicort

CONTROLADORES DE ASMA

Advair Diskus

Asmanex Twisthaler

Advair HFA

Flovent HFA

Pulmicort Respules

Qvar

Qvar

Pulmicort Flexhaler

ASTHMA RELIEVERS

Generic Albuterol

ProAir HFA

Ventolin HFA

Proventil HFA

Xopenex HFA

Xopenex Nebulizer Solution

Albuterol Nebulizer Solution

Singulair

Symbicort

ASTHMA CONTROLLERS

Advair Diskus

Asmanex Twisthaler

Advair HFA

Flovent HFA

Pulmicort Respules

Qvar

Qvar

Pulmicort Flexhaler

Formulario #2: ¿qué tan bien controlado Está su asma?

Formulario Estudio ACE #2: Indicador de Control Página 1 de 1

¡Mi asma está muy bien! No me molesta de nada.

El asma no está mala, pero podría ser mejor. Sólo me molesta a veces.

El asma me molesta a menudo. Sin duda podría ser mejor.

El asma me molesta mucho y que me impide hacer las cosas que quiero hacer.

Form #2: How well controlled is your asthma?

ACE Study Form #2: Control Dial Page 1 of 1

My asthma is not bad,

but it could be better.

It only bothers me

sometimes.

My asthma is doing

great! It doesn’t bother

me much at all.

My asthma bothers me

more often than not. It

could definitely be better.

My asthma bothers

me a lot and keeps

me from doing

things I want to do.

Formulario #3: Metas para el tratamiento del asma de: _________________________________

Actividades que me gusta hacer:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

___________________________________________________________________________________________

Otras preocupaciones:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Importante a mí Importante a

mis padres

Estamos de acuerdo que las metas más importantes son:

Trabajen juntos para poner en orden de importancia (1-5)

No tengan Efectos Secundarios

No cuesten tanto

Sean fáciles de tomar y recordar

Otro:

Controlen la hinchazón/inflamación en mis

pulmones y controlen mis síntomas

Quiero que mis medicamentos de asma ...

*Pon un cheque para significar cual es importante a �.

Form #3: ____________’s Asthma Treatment Goals

Activities I’d like to do:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Other Concerns:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Important To

Me

Important To

My Parent

We agree that the most

important goals are:

Not have Side Effects

Not Cost a lot

Be Easy to take and remember

Other:

Control swelling/inflammation in my lungs

and my symptoms

I want my asthma medicine to...

*Place a check to show what is important to you.

Formulario #4: Hechos Sobre el Asma

Con Control Sin Control

El asma es una enfermedad de las vías respiratorias en los pulmones. Cuando una persona con

asma respira uno de sus "causantes o detonantes”, de asma hace que sus vías respiratorias se

vuelven más pequeños. Esto se llama "broncoespasmo." Esto hace que sea más difícil respirar y

puede causar un ataque de asma.

Hinchazón/Inflamación

Moco extra

Músculos apretados

Hinchazón

Moco

Extra

Músculos

Apretados

Las 3 cosas principales que causan que las vías respiratorias se hagan mas pequeñas.:

Hay Dos Tipos de Medicamentos de Asma

Controlador Alivio • Estos medicamentos se toman solo cuando uno tiene

síntomas para aliviar los síntomas inmediatamente.

• Medicamentos de rescate alivian la tensión de los

músculos alrededor de los tubos el aire

• Dile a su médico si usas estos más de dos veces a la

semana. Puede que necesite un medicamento de control

más fuerte.

• Estos medicamentos se toman cada día para prevenir

y controlar los síntomas del asma.

• No alivian los síntomas una vez que empiezan.

• Los controladores trabajan lentamente con el tiempo

para disminuir la hinchazón y el moco adicional en los

tubos de su aire.

Ejemplos:

Ejemplos:

Hinchazón/ inflamación

Moco extra

Músculos apretados

Hinchazón/ inflamación

Moco extra

Músculos apretados

Generic Albuterol Ventolin HFA

Albuterol Nebulizer

Solution Proventil HFA

ProAir HFA Xopenex Nebulizer

Solution

Xopenex HFA

Symbicort Asmanex

Twisthaler

Singulair Advair Diskus Advair HFA

Qvar Pulmicort Respules Flovent HFA Pulmicort Flexhaler

Form #4: Facts About Asthma

In Control NOT in Control

Asthma is a disease of the airways in your lungs. When someone with asthma breathes in one

of their “triggers,” it causes their airways to get smaller. Doctors call this “bronchospasm.”

This makes it harder to breathe and can lead to an asthma attack.

Swelling/Inflammation

Extra Mucus

Tightening Muscles

Tightening

Muscles

Swelling

Extra

Mucus

3 main things cause the airways to get smaller:

There are 2 types of Asthma Medications

Controller Rescue

• These medicines are only taken when you have

symptoms to relieve asthma symptoms right away.

• Rescue medicines relieve the tightening of muscles

around your air tubes.

• Tell your doctor if you use these more than 2 times a

week. You may need a stronger controller medication.

• These medicines are taken every day to prevent and

control asthma symptoms.

• They do NOT relieve symptoms once they start.

• Controllers work slowly over time to decrease

swelling and extra mucus in your air tubes.

Examples:

Examples:


Extra Mucus

Tightening Muscles


Extra Mucus

Tightening Muscles

Generic Albuterol Ventolin HFA

Albuterol Nebulizer

Solution Proventil HFA

ProAir HFA Xopenex Nebulizer

Solution

Xopenex HFA

Symbicort Asmanex

Twisthaler

Singulair Advair Diskus Advair HFA

Qvar Pulmicort Respules Flovent HFA Pulmicort Flexhaler

Formulario 5: Alergias: cosas que puede hacer para controlar sus síntomas

¿Qué causa las alergias?

Cuando su cuerpo tiene una reacción exagerada a cosas que no le causan problemas a la mayoría de la gente usted tiene una alergia. Estas cosas se llaman alergenos. La reacción exagerada de su cuerpo contra los alergenos es lo que causa los síntomas. Vea la lista de síntomas en la tabla de abajo. Por ejemplo, algunas veces el término "fiebre del heno" se usa para describir la reacción alérgica de su cuerpo a alergenos estacionales en el aire tales como pasto o polen. Su médico puede querer que usted se haga una prueba cutánea para alergias para determinar de manera exacta qué le está causando alergia. En una prueba cutánea para las alergias a usted le ponen cantidades diminutas de alergenos sobre la piel para ver a cuáles usted reacciona. Una vez que usted sabe a cuáles alergenos es alérgico, usted y su médico pueden decidir el mejor curso de tratamiento. Es posible que su médico decida hacerle también una prueba de sangre tal como una prueba de radioalergoadsorción (RAST en inglés).

Síntomas comunes de la alergia:

• Nariz con mucosidad • Ojos llorosos • Comezón en la nariz, ojos y en el paladar duro • Estornudos • Congestión nasal. • Presión en la nariz y en los cachetes • Los oídos están tupidos y a veces se destapan • Ojeras • Urticaria

¿Cuáles son los tipos más comunes de alergenos?

Polen de árboles, pastos y malezas.Las alergias que ocurren en la primavera (al final de abril y en mayo) con frecuencia son por causa de polen de árboles. Las alergias que ocurren en el verano (del final de mayo hasta la mitad de julio) con frecuencia son por causa de polen de pasto y de maleza. Las alergias que ocurren en el otoño (del final de agosto hasta la primer helada) por lo general son por causa de una maleza del género Ambrosía. Moho. El moho es común en los lugares donde el agua tiende a acumularse; tal como en las cortinas de baño, en los marcos de las ventanas y en los sótanos húmedos. También puede encontrarse en troncos de madera en estado de descomposición, heno, pajote, turba de sphagnum comercial, pilas de abono y desechos de hojas. Esta alergia usualmente empeora cuando el clima es húmedo y lluvioso. Caspa animal. Las proteínas que se encuentran en la piel, saliva y orina de los animales peludos tales como gatos y perros son alergenos. Usted puede exponerse a caspa al alzar un animal o en el polvo de una casa que contiene caspa. Polvo. Muchos alergenos incluso los ácaros del polvo están presentes en el polvo. Los ácaros del polvo son pequeñas criaturas que se encuentran en las camas, colchones, alfombras y tapicería de los muebles. Estas criaturas se alimentan de las células muertas y de otras cosas que se encuentran en el polvo de las casas.

Cosas que pueden hacer que sus síntomas de alergia empeoren

• Partículas aerosolizadas • Polución del aire • Temperaturas frías

• Humedad • Vapores irritantes • Humo del tabaco • Viento • Humo de madera

¿Cómo puedo evitar los alergenos?

Pólenes. Tome un baño o dúchese antes de acostarse para eliminar el polen y demás alergenos de su pelo y piel. Evite salir afuera especialmente en días secos y en que hace viento. Mantenga cerradas las ventanas y las puertas y use un aire acondicionado en su casa y en su carro. Moho. Usted puede disminuir la cantidad de moho en su casa removiendo las plantas y limpiando con frecuencia las cortinas de baño, las ventanas de los baños, las paredes húmedas, las áreas con madera podrida que esté seca y los botes de basura dentro de su casa. Use una mezcla de agua y lejía (hipoclorito de sodio) para matar el moho. Abra puertas y ventanas y use abanicos (ventiladores) para aumentar el movimiento del aire y ayudar a prevenir la formación de moho. No entapete los baños ni ningún otro cuarto húmero y use pintura resistente al moho en vez de papel decorativo para paredes. Disminuir la humedad en su casa a 50% o menos también le puede ayudar. Usted puede controlar la calidad del aire en su casa usando un deshumidificador, manteniendo el termostato de su casa fijo en 70 grados Fahrenheit (21 Celsius) y limpiando o reemplazando los filtros de partículas pequeñas en su aire acondicionado central. Caspa animal. Si sus alergias son graves, es posible que tenga que deshacerse de sus mascotas o por lo menos tenerlas fuera de la casa. La caspa de los gatos o de los perros con frecuencia se acumula en el polvo de la casa y se toma cuatro semanas para desaparecer por completo. Sin embargo, existen maneras de disminuir la cantidad de caspa animal dentro de su casa. Usar ropa de cama resistente a los alergenos, bañar su mascota con frecuencia y usar un filtro de aire pueden ayudar a disminuir la caspa animal. Pregúntele a su veterinario acerca de otras maneras para disminuir la caspa animal dentro de su casa. Polvo y ácaros del polvo. Para disminuir los ácaros del polvo dentro de su casa deshágase de cortinas, almohadas de plumas, muebles tapizados, cubrelechos que no se puedan lavar y juguetes de peluche. Remplace las alfombras con piso de linoleo o de madera. Los pisos pulidos son lo mejor. Trapee el piso con frecuencia con un trapero húmedo y limpie las superficies con un trapo húmedo. Aspire el piso con frecuencia con una máquina que tenga un filtro de aire de alta eficiencia para partículas suspendidas (HEPA). Aspire los muebles suaves y las cortinas al igual que los pisos. Instale un purificador de aire con un filtro de alta eficiencia para partículas suspendidas o un filtro electrostático. Lave las alfombras y los muebles con limpiadores especiales tales como benzoato de bencilo o un aerosol de ácido tánico. Lave toda la ropa de cama en agua caliente: a más de 130°F (54.44°C) cada siete o diez días. No use protect ores para colchones. Cubra los colchones y las almohadas con protectores de plástico. Disminuya la humedad en su casa.

¿Qué medicamentos puedo tomar para ayudar a aliviar mis síntomas?

Los antihistamínicos ayudan a disminuir los estornudos, la mucosidad en la nariz y la comezón producida por las alergias. Estos son más útiles si usted los usa antes de ser expuesto a los alergenos. Algunos antihistamínicos pueden causar somnolencia y resequedad en la boca. Otros tienen menos probabilidad de causar estos efectos secundarios, pero algunos de estos requieren una receta (prescripción) médica. Pregúntele a su médico qué tipo es mejor para usted. Descongestionantes , tales como seudoefedrina y fenilefrina ayudan a aliviar temporalmente la congestión nasal que ocurre en las alergias. Los descongestionantes están presentes en muchos medicamentos que se venden en forma de tabletas, aerosoles nasales y gotas para la nariz. Es mejor usarlos sólo por un tiempo corto. Los aerosoles nasales y las gotas no deben usarse más de tres días pues usted puede habituarse a usarlos. Esto hace que usted sienta su nariz aún más tupida cuando trata de dejar de usarlos. Los descongestionantes pueden comprarse sin receta médica. Sin embargo, los descongestionantes pueden elevarle la presión arterial (sanguínea); por lo tanto, es buena idea hablar con su médico de familia antes de usarlos, especialmente si usted sufre de presión arterial alta. Cromolina sódica (de sodio) es un aerosol nasal que ayuda a prevenir las reacciones corporales a los alergenos. La

cromolina sódica es más útil si usted la usa antes de ser expuesto a los alergenos. Este medicamento puede tomar entre dos y cuatro semanas para comenzar a actuar. Se puede comprar sin receta médica Los aerosoles nasales esteroideos reducen la reacción de los tejidos nasales a los alergenos inhalados. Esto ayuda a aliviar la hinchazón en su nariz de modo tal que usted se siente menos tupido. Vienen en forma de aerosoles nasales que su médico le receta. Usted no notará los beneficios de estos hasta dos semanas después de comenzar a usarlos. Su médico le puede recetar tabletas de esteroides durante un período de tiempo corto o le puede poner una inyección de esteroides si sus síntomas son graves o si otros medicamentos no le están funcionando. Gotas para los ojos. Si los demás medicamentos no lo están ayudando lo suficiente con la comezón y el lagrimeo en los ojos, su médico puede recetarle gotas para las ojos.

¿Qué son inyecciones para alergias?

Las inyecciones para alergias, también llamadas inmunoterapia, contienen pequeñas cantidades de alergenos. Estas se ponen a intervalos regulares de tiempo, de modo tal que su cuerpo se acostumbra a los alergenos y no muestra más una reacción exagerada ante estos. Las vacunas para las alergias se usan únicamente cuando se pueden identificar los alergenos a los cuales usted es sensible y cuando usted no puede evitarlos. Se toma desde unos pocos meses hasta años para terminar el tratamiento, y es posible que usted necesite recibir este tratamiento de por vida.

Fuente

Escrito por el personal editorial de familydoctor.org.

Academia Estadounidense de Médicos de Familia

Revisado/Actualizado: 10/09 Creado: 10/01

Copyright © 2001-2011 American Academy of Family Physicians Página inicial | Página inicial en español | Política de Privacidad

Contactarnos | Sobre Este Sitio | Política para publicidad

Formulario 6: Fumar: pasos para ayudarle a eliminar el hábito

¿Porqué parece tan difícil dejar de fumar?

Fumar ocasiona cambios en su cuerpo y en la manera como usted actúa. Los cambios en su cuerpo son causados por una adicción a la nicotina. Los cambios en la manera como usted actúa se desarrollaron con el tiempo a medida que usted compró cigarrillos, los encendió y se los fumó. Estos cambios se han convertido en su hábito de fumar. Cuando usted tiene el hábito de fumar, muchas cosas parecen ir mano a mano con tener un cigarrillo. Éstas pueden incluir tomarse una taza de café o una bebida que contiene alcohol, estar estresado o preocupado, hablar por teléfono, manejar, estar en la compañía de amigos o querer tener algo que hacer con las manos.

¿Cómo puedo dejar de fumar?

Usted tendrá la mejor probabilidad para dejar de fumar si hace lo siguiente:

• Prepárese • Obtenga apoyo y estímulo • Aprenda a manejar el estrés y el impulso de fumar • Obtenga medicamento y úselo correctamente • Prepárese para una recaída • Siga intentando

¿Cómo debo prepararme para dejar de fumar?

Fíjese una fecha para parar en un plazo de 2 a 4 semanas de modo que usted tenga tiempo para prepararse. Escriba sus razones personales para dejar de fumar. Sea específico. Mantenga su lista consigo mismo de modo que la pueda mirar cuando sienta el impulso de fumar. Para ayudarle a comprender su hábito de fumar lleve un diario de cuándo y cuánto fuma. Usando información que encuentra en este diario usted y su médico pueden hacer un plan para lidiar con las cosas que hacen que usted quiera fumar. Justo antes de la fecha en que va a dejar de fumar deshágase de todos sus cigarrillos, fósforos, encendedores y ceniceros. La siguiente guía muestra los pasos que debe tomar antes, durante y después de la fecha de dejar de fumar: Guía para dejar de fumar (PDF de 1 página).

Razones inmediatas para dejar de fumar

• Mal aliento y dientes manchados • Mal olor en la ropa, cabello y en la piel • Menor capacidad atlética • Tos y dolor de garganta • Latidos del corazón más fuertes y aumento de la presión sanguínea • El riesgo de exponer indirectamente a la gente alrededor suyo al cigarrillo. • El costo de fumar

Razones a largo plazo para dejar de fumar

• Químicos tóxicos en el humo del cigarrillo • Riesgo de cáncer del pulmón y de muchos otros tipos de cáncer • Riesgo de enfermedad del corazón • Problemas de respiración graves • Tiempo de trabajo y de diversión perdido por estar enfermo • Arrugas • Riesgo de úlceras estomacales y de reflujo ácido • Riesgo de enfermedad de las encías • Riesgo de causarle daño a los bebés en mujeres embarazadas que fuman • Darle mal ejemplo a sus hijos

¿Cómo puedo obtener apoyo y estímulo?

Dígale a su familia y a sus amigos qué tipo de ayuda quiere. Su apoyo le hará más fácil a usted dejar de fumar. Además, pídale a su médico de familia que le ayude a desarrollar un plan para dejar de fumar. Él o ella le puede dar información a usted sobre líneas de teléfono de emergencia "Hotlines" tales como 1-800-QUIT-NOW (784-8669), o materiales de ayuda personal que pueden serle muy útiles. Su médico también puede recomendarle un programa para dejar de fumar. Por lo general, estos programas los hacen en hospitales o centros de salud locales. Recompénsese usted mismo por dejar de fumar. Por ejemplo, con el dinero que ahorra por no fumar cómprese algo especial.

¿Y con respecto a la terapia de reemplazo de nicoti na o al medicamento para ayudarme a dejar de fumar?

Los productos para remplazar la nicotina son formas de tomar nicotina sin fumar. Estos productos vienen en varias presentaciones: goma de mascar, parches, aerosoles nasales, inhaladores y pastillas. Usted puede comprar la goma de mascar con nicotina, el parche y la pastilla sin receta médica. La terapia de reemplazo de la nicotina funciona aminorando el antojo que usted siente por fumar y reduciendo los síntomas de abstinencia. Esto le permite enfocarse en los cambios que usted necesita hacer en cuanto a sus hábitos y su ambiente. Una vez que usted se siente más seguro de si mismo como un no fumador, lidiar con su adicción a la nicotina es más fácil. Los medicamentos que se obtienen con receta tales como bupropion SR (un nombre de marca: Zyban) y vermeil (nombre de marca: Chantix) ayudan a algunas personas a dejar de fumar. Estos medicamento no contienen nicotina, pero le ayudan a resistir las ansias de fumar. Hable con su médico acerca de cuál de estos productos es más probable que le de el mayor chance de éxito. Para que cualquiera de estos productos funcione usted debe seguir cuidadosamente las instrucciones que están descritas en el paquete. Es muy importante que usted no fume mientras usa productos para reemplazar la nicotina.

¿Qué va a pasar cuando deje de fumar?

La manera cómo usted se siente cuando deje de fumar dependerá de cuánto ha fumado, de qué tan adicto está su cuerpo a la nicotina y de qué tan bien se prepara para dejar de fumar. Usted puede tener antojos de un cigarrillo o sentir más hambre de lo normal. Usted puede sentirse irritable y tener dificultad para concentrarse. Al principio usted puede también toser más y puede tener dolores de cabeza. Estas cosas pasan porque su cuerpo está acostumbrado a la nicotina. Se llaman síntomas de abstinencia de la nicotina. Estos síntomas son más fuertes durante los primeros días después de que usted deja de fumar pero la mayor parte de ellos desaparece en unas pocas semanas.

¿Y con respecto a la terapia de reemplazo de nicoti na o al medicamento para ayudarme a dejar de fumar?

Los productos para reeemplazar la nicotina son formas de tomar nicotina sin fumar. Estos productos vienen en varias presentaciones: goma de mascar, parches, aerosoles nasales, inhaladores y pastillas. Usted puede comprar la goma de

mascar con nicotina, el parche y la pastilla sin receta médica. La terapia de reemplazo de la nicotina funciona aminorando el antojo que usted siente por fumar y reduciendo los síntomas de abstinencia. Esto le permite enfocarse en los cambios que usted necesita hacer en cuanto a sus hábitos y su ambiente. Una vez que usted se siente más seguro de si mismo como un no fumador, lidiar con su adicción a la nicotina es más fácil. Un medicamento que se obtiene con receta médica llamado bupropion SR (nombres de marca: Zyban, Wellbutrin SR) ayuda a algunas personas a dejar de fumar. Se toma en forma de pastilla. El Bupropion SR no contiene nicotina pero le ayuda a resistir sus impulsos de fumar. Hable con su médico acerca de cuál de estos productos es más probable que le de el mayor chance de éxito. Para que cualquiera de estos productos funcione usted debe seguir cuidadosamente las instrucciones que están descritas en el paquete. Es muy importante que usted no fume mientras usa productos para reemplazar la nicotina.

¿Voy a subir de peso cuando deje de fumar?

La mayoría de las personas aumentan unas pocas libras después de que dejan de fumar. Recuerde que cualquier aumento de peso es un riesgo de salud pequeño comparado con los riesgos de fumar. Hacer dieta mientras está tratando de dejar de fumar le ocasionará un estrés innecesario. En vez de esto, limite la cantidad de peso que aumenta teniendo a la mano bocados pequeños ("snacks") y saludables con un contenido bajo en grasa y estando activo físicamente.

¿Qué pasa si fumo de nuevo?

No se sienta fracasado. Piense por qué fumó y qué puede hacer para no volver a fumar de nuevo. Fíjese una nueva fecha para dejar de fumar. Muchos ex-fumadores no tuvieron éxito al principio pero siguieron tratando. Los primeros días después de dejar de fumar probablemente serán los más difíciles. Simplemente recuerde que incluso una bocanada de cigarrillo le puede causar una recaída, por lo tanto, no se arriesgue.

Fuente

Escrito por el personal editorial de familydoctor.org.

Academia Estadounidense de Médicos de Familia

Revisado/Actualizado: 12/09 Creado: 10/01

Copyright © 2001-2011 American Academy of Family Physicians Página inicial | Página inicial en español | Política de Privacidad

Contactarnos | Sobre Este Sitio | Política para publicidad

Formulario #7: ¿qué tan grave está su asma?

• Síntoma ≤ de 2 días por semana • Sin despertarse por las noches • No interfiere con la actividad normal • Uso del Albuterol (medicina de rescate) ≤ de 2 días por semana • Reagudizaciones que requieren esteroides por via

oral de 0 a 1 vez al año

• Síntomas diariamente • Se despierta por las noches de 3 a 4

veces por mes • Algunas limitaciones con ciertas ac tividades normales • Uso diario del Albuterol (medicina de rescate) • Reagudizaciones que requieren es-

teroides por via oral 2 ó más veces durante 6 meses

• Síntomas durante todo el día • Se despierta por las noches más de 1 vez por semana • Limitación extrema durante la actividad normal • Uso del Albuterol (medicina de rescate) varias

veces al día • Reagudizaciones que requieren esperoides por

via oral 2 días o más durante 6 meses

• Los síntomas más de 2 días por semana, pero no diariamente • Se despierta por las noches de 1 a 2 veces

por mes • Pocas limitaciones durante las activi dades normales • Uso del Albuterol (medicina de rescate)

más de 2 días por semana, pero no diariamente • Reagudizaciones que requieren esteroides

por via oral 2 o más veces durante 6 meses

Formulario Estudio ACE #6: Indicador con Descriptores Página 1 de 1

Paso 1

Paso 2

Paso 3

Paso 3

Usar este indicador para los pacientes que NO están recibiendo medicamentos de control para iniciar tratamiento De 2 a 4 Años de Edad

• Síntomas ≤ de 2 días por semana • Se despierta por las noches ≤ de 1 vez por mes • No interfiere durante la actividad normal • Uso del Albuterol (medicina de rescate) ≤ de 2 días por semana • Reagudizaciones que requieren esteroides por via

oral de 0 a 1 vez al año

• Síntomas durante todo el día • Se despierta durante las noches > de 1 vez a la semana • Limitación extrema durante la actividad normal • Uso del Albuterol (medicina de rescate)

varial veces al día • Reagudizaciones que requieren esteroides

por via oral > de 3 veces al año

• Síntomas > de 2 días por semana • Se despierta durante las noches > de 1

vez por mes • Algunas limitaciones durante la activi dad normal • Uso del Albuterol (medicina de rescate)

> de 2 días por semana • Reagudizaciones que requieren es-

teroides por via oral entre 2 a 3 veces al año

Mantener el paso actual o retro-ceder si está bien controlada

durante 3 meses

Avanzar 1 paso y evaluar nuevamente en 2 a 6 semanas

Avanzar de 1 a 2 pasos y evalu-ar nevamente en 2 semanas y considerer una serie de es-

teroides por via oral

Formulario #7: ¿Qué tan bien controlado está su asma?

Usar este indicador para los pacientes que reciben medicamentos para controlar y en las visitas de seguimiento De 2 a 4 Años de Edad

Formulario Estudio ACE #6: Indicador con Descriptores Página 1 de 1

Form #7: How severe is your asthma?

• Symptoms ≤ 2 days a week • No nighttime awakenings • No interference with normal activity • Albuterol use (rescue medicine) ≤ 2 days a week • Exacerbations requiring oral steroids 0-1 times a

year

• Symptoms daily • Nighttime awakenings 3-4 times per

month • Some limitation with normal activity • Albuterol use (recue medicine) daily • Exacerbations requiring oral steroids

≥ 2 times in 6 months

• Symptoms throughout the day • Nighttime awakenings > 1 times per week • Extreme limitation with normal activity • Albuterol use (rescue medicine) several

times a day • Exacerbations requiring oral steroids ≥ 2

times in 6 months

• Symptoms > 2 days a week, but not daily • Nighttime awakenings 1-2 times per

month • Minor limitation with normal activity • Albuterol use (rescue medicine) > 2 days

a week, but not daily • Exacerbations requiring oral steroids ≥ 2

times in 6 months

ACE Study Form #7: Dial with Descriptors Page 1 of 1

Step 1

Step 2

Step 3

Step 3

Use this dial for patients NOT on controller medication to initiate treatment 2-4 Years Old

• Symptoms ≤ 2 days a week • Nighttime awakenings ≤ 1 time a month • No interference with normal activity • Albuterol use (rescue medicine) ≤ 2 days a week • Exacerbations requiring oral steroids 0-1 times a

year

• Symptoms throughout the day • Nighttime awakenings > 1 time a week • Extreme limitation with normal activity • Albuterol use (rescue medicine) several

times a day • Exacerbations requiring oral steroids > 3

times a year

• Symptoms > 2 days a week • Nighttime awakenings > 1 time a month • Some limitation with normal activity • Albuterol use (rescue medicine) > 2 days

a week • Exacerbations requiring oral steroids 2-3

times a year

Maintain current step or step down if well

controlled for 3 months

Step up 1 step and reevaluate in 2-6 weeks

Step up 1-2 steps and reevaluate in 2 weeks plus consider oral steroid course

Form #7: How well controlled is your asthma?

Use this dial for patients on controller medication and at follow-up visits 2-4 Years Old

ACE Study Form #7: Dial with Descriptors Page 1 of 1

Step 6

Step 1

Step 2

Step 3

Step 4

Step 5

Medication Options to Control Asthma 2-4 Years Old

Medicaid Insurance

For Singulair – must complete PA and have documentation of adverse reaction/contraindication to ICS, growth suppression due to ICS, or be on medium dose ICS needing Singulair to achieve control

*Advair may not be used until 4 years old; must complete PA indicating pt’s condition is severe enough to warrant ICS/LABA combination product

**Advair Diskus may be difficult to use in this age group; Advair HFA is considered off-label under 12 years old For severe persistent asthmatics with allergies may combine Advair with Singulair - listed below as “Additional” Flovent may be obtained through PA

Preferred SABA PRN

Albuterol – 1 neb

every 4-6 hours prn

Preferred Low-Dose ICS

Pulmicort Respules 0.25/2 –

1 neb once a day

Alternative LTRA

Singulair 4 – 1 daily

Preferred Medium-Dose ICS


1 neb twice a day

Pulmicort Respules 0.5/2 – 1 neb once a day

Preferred Medium-Dose ICS + LABA

*Advair Diskus 100/50 –

1 puff twice a day

**Advair HFA 45/21 – 2 puffs twice a day

Preferred

Medium-Dose ICS + LTRA

Pulmicort Respules 0.25/2 – 1 neb twice a day + Singulair 4 – 1 daily

Pulmicort Respules 0.5/2 – 1 neb once a day + Singulair 4 – 1 daily

Additional

Med-Dose ICS + LABA + LTRA

Less Preferred

*Advair Diskus 100/50 – 1 puff once a day

**Advair HFA 45/21 –

2 puffs once a day

Preferred High-Dose ICS + LABA

*Advair Diskus 100/50 –

1 puff twice a day


Preferred

High-Dose ICS + LTRA


Pulmicort Respules 0.5/2 – 2 nebs once a day + Singulair 4 – 1 daily

Additional

High-Dose ICS + LABA + LTRA

Less Preferred


**Advair HFA 45/21 –

2 puffs once a day

Pulmicort Respules 0.5/2 – 2 nebs once a day

Preferred

Same as Step 5 + Oral Steroid Course

Step 6

Step 1

Step 2

Step 3

Step 4

Step 5

Medication Options to Control Asthma 2-4 Years Old

Commercial Insurance

*Flovent, Asmanex and Advair may not be used until 4 years old **Advair Diskus may be difficult to use in this age group; Advair HFA is considered off-label under 12 years old For severe persistent asthmatics with allergies may combine Advair with Singulair - listed below as “Additional”

Preferred SABA PRN

Albuterol – 1 neb

every 4-6 hours prn

Preferred Low-Dose ICS


1 neb once a day

*Flovent HFA 44 – 1 puff twice a day

Alternative LTRA

Singulair 4 – 1 daily

Preferred Medium-Dose ICS


1 neb twice a day


*Flovent HFA 44 – 2 puffs twice a day

*Asmanex 110 – 1 puff once a day

Less Preferred

*Flovent HFA 44 – 2 puffs once a day

Preferred Medium-Dose ICS + LABA

*Advair Diskus 100/50 – 1 puff twice a day


Preferred

Medium-Dose ICS + LTRA



*Flovent HFA 44 – 2 puffs

twice a day + Singulair 4 – 1 daily

*Asmanex 110 – 1 puff once a day + Singulair 4 – 1 daily

Additional

Medium-Dose ICS + LABA + LTRA

Less Preferred


**Advair HFA 45/21 – 2 puffs once a day

*Flovent HFA 44 – 2 puffs once a day + Singulair 4 – 1 daily

Preferred High-Dose ICS + LABA

*Advair Diskus 100/50 – 1 puff twice a day


Preferred

High-Dose ICS + LTRA




+ Singulair 4 – 1 daily

*Asmanex 110 – 1 puff once a day + Singulair 4 – 1 daily

Additional

High-Dose ICS + LABA + LTRA

Less Preferred


**Advair HFA 45/21 – 2 puffs once a day

*Flovent HFA 44 – 4 puffs once a day + Singulair 4 – 1 daily



Preferred

Same as Step 5 + Oral Steroid Course

Formulario #9: Planificador de Medicamentos

de ____________________

Lo que mis

padres y yo

hemos decidos es

lo mas imporant:

Los medicamentos

que tomo ahora:

________________

________________

Opción #1

______________

______________

______________

Opción #2:

______________

______________

______________

Opción #3:

______________

______________

______________

1.

2.

3.

4.

5.

Puedo cambiar mis medicamentos de asma a:

El medicamento de asma que mis padres y yo escogimos es:

_________________________________________________

Form #9: ___________’s Medication Planner

What My Parent

and I Decided is

Most Important:

Medicine I take now:

________________

________________

________________

Pick #1:

______________

______________

______________

Pick #2:

______________

______________

______________

Pick #3:

______________

______________

______________

1.

2.

3.

4.

5.

I can change my asthma medicine to….

The asthma medicine my parent and I pick is:

_________________________________________________

� Medicamentos para controlar: � Previenen que los síntomas del asma ocurran

� Pueden reducir y/o prevenir:

� Inflamación en las vías respiratorias

� Tensión de las bandas musculares alrededor de las vías respira-

torias

� No muestran resultados inmediatos pero trabajan lentamente con el

tiempo

� Deben recibirse diariamente aún cuando no se tengan síntomas

� NO deben usarse para aliviar síntomas inmediatos del asma

� Medicamentos para aliviar: � Alivian los síntomas del asma una vez que han comenzado

� Relaja las bandas musculares tensas alrededor de las vías respirato-

rias

� Trabajan inmediatamente

� Se necesitan con poca frecuencia (no más de dos veces por semana)

� Si los medicamentos para aliviar se necesitan más de dos veces por

semana, esto indica que el tratamiento preventivo es inadecuado y la

inflamación está mal controlada

FORMULARIO #10: T IPOS GENERALES DE MEDICAMENTOS PARA EL ASMA

Formulario de estudio ACE #10: Tipos de medicamento, Página 1 de 6

� Un agonista beta, tal como albuterol, relaja los músculos alrededor de las vías respiratorias durante el bronco

espasmo lo cual permite que el aire se mueva más libremente a través de las vías. Los agonistas beta de acción

temporal también se usan a veces antes de hacer ejercicio para prevenir un bronco espasmo. Aunque los ago-

nistas beta de acción temporal son los medicamentos más comúnmente recetados para el asma, también son

los que deben usarse con menos frecuencia porque no ayudan con el control del asma a largo plazo.

Hay dos tipos generales de medicamentos agonistas beta:

� La preparación de acción temporal se llama de “rescate” o “medicamento para alivio” porque se

usa para rescatar de los síntomas agudos del asma y proporcionar alivio. Albuterol es de esta clase.

� La preparación de acción prolongada se usa para prevenir el bronco espasmo y controlar el asma y

por eso se llama un “medicamento controlador.” Serevent® (salmeterol) y Foradil Aerolizer®

(formoterol) son agonistas beta de acción prolongada. Las preparaciones de acción prolongada nunca

deben usarse para rescatar o aliviar síntomas graves del asma, tal como una reagudización.

� Los agonistas beta de acción temporal tales como albuterol (ejemplos: Ventolina, Proventil, o ProAir) son

con más frecuencia recetados como aerosoles que se soplan en los pulmones utilizando un inhalador o un ne-

bulizador. El inhalador requiere coordinación de la mano y la respiración para utilizarlo. Si tiene problema al

utilizar un inhalador, puede hacerlo con un espaciador tal como el Aerochamber (en inglés), el cual permite

que las partículas del medicamento penetren profundamente en los pulmones. Es buena idea llevar consigo su

inhalador de rescate dondequiera que vaya. Es igualmente importante no llevar consigo durante el día, un

agonista beta de acción prolongada como Serevent® o Foradil®, puesto que debe usarse solamente una o dos

veces al día con un horario regular, por ejemplo, temprano en la mañana y/o en la noche.

� Los agonistas beta de acción temporal (llamados también adrenérgicos broncodilatadores) vienen en tableta o

en forma líquida. Estas formas de los medicamentos actúan un poco más despacio y pueden producir más

efectos secundarios pero aún son efectivos. Para alivio de emergencia, el médico puede administrar agonistas

beta por medio de un nebulizador.

� Los efectos secundarios posibles de agonistas beta incluyen ritmo cardíaco irregular o rápido, nerviosismo,

temblor muscular, insomnio, náusea y vómito. El uso excesivo de estos medicamentos puede producir

aumento de receptividad bronquial (esto es cuando las vías respiratorias que ya están “espasmódicas” debido

al asma, pueden ponerse aún más espasmódicas o más receptivas).

Usar más de una frasco de albuterol al mes (o usarlo más de dos veces por semana) indica que se necesita

tratamiento adicional (preventivo) con un medicamento controlador del asma.

� Si necesita más de 8 inhalaciones de un agonista beta de acción temporal al día , es signo de “alerta” que su

asma está fuera de control. No debe necesitar más de 2 en 24 horas excepto en circunstancias poco usuales.

ALBUTEROL Y OTROS AGONISTAS BETA DE ACCIÓN TEMPORAL


� Los corticosteroides inhalados son un tipo de medicamento recetado comúnmente a las personas con asma

persistente. Aunque tienen un nombre similar, “corticosteroides” son muy diferentes de “esteroides

anabólicos” los cuales son a veces usados ilegalmente por atletas para aumentar la masa muscular.

� Los corticosteroides son el medicamento antinflamatorio más eficaz que se consigue. En forma de crema son

usados comúnmente para tratar irritaciones de la piel. Porque el problema principal de los pulmones en el

asma es una inflamación crónica que estrecha las vías respiratorias y hace difícil respirar, los corticosteroi-

des se usan a menudo para tratarla. También ayudan a reducir o prevenir la tumefacción o hinchazón

(causada por inflamación) y el exceso de mucosidad en los tubos bronquiales.

� Los corticosteroides no relajan los músculos alrededor de los tubos bronquiales. Ellos no abren las vías res-

piratorias inmediatamente como lo hacen los broncodilatadores tales como albuterol. Por esta razón, los

corticosteroides no parecen tener ningún efecto benéfico. No obstante, cuando se reciben regularmente por

un tiempo, reducen la inflamación subyacente y la sensibilidad de las vías respiratorias. Los corticosteroides

tratan síntomas que no son afectados por los broncodilatadores. Para la mayoría de las personas con asma,

los corticosteroides son sencillamente el medicamento más eficaz porque rompen el ciclo inflamatorio y

reducen la posibilidad de episodios de asma futuros. Son parte esencial en el manejo del asma moderada o

grave en los niños y adultos.

� Los corticosteroides inhalados se administran usando un inhalador o algunas veces un nebulizador. Ellos son

“medicamentos controladores,” lo cual significa que se reciben para prevención de los síntomas. A

menos que tenga instrucciones especiales de su médico, no comience con esteroides inhalados durante un

episodio de asma; sin embargo, si los recibe regularmente, no deje de usarlos cuando tenga los síntomas.

� Es importante reconocer que las preocupaciones comunes acerca del uso de corticosteroides orales no apli-

can a los inhalados porque el cuerpo no los absorbe en gran medida.

� Una porción pequeña de personas experimenta algunos efectos secundarios locales como:

� Estomatitis/muguet: infección de hongos en la boca, lengua o garganta (causa puntitos blancos)

� Ronquera (algunas veces)

� Estos efectos secundarios generalmente se pueden evitar usando un espaciador, como Aerochamber, con el

inhalador, enjuagándose la boca después de cada tratamiento y manteniendo limpio el inhalador.

� Aunque las dosis muy altas de corticosteroides inhalados tienen el potencial de causar los mismos efectos

secundarios de los corticosteroides orales, sus beneficios son mayores que cualquier efecto negativo posible.

Aún en dosis altas, la dosis de corticosteroides inhalados que llega al cuerpo es generalmente sólo una frac-

ción pequeña en comparación a la dosis oral y los efectos secundarios son mucho menos graves.

� Advertencia: Si desarrolla un episodio grave de asma que no responde a los medicamentos usuales, es im-

portante comunicarse de inmediato con un médico. El episodio grave puede impedirle inhalar su corticoste-

roide usual en los pulmones y tal vez necesite una “ absorción rápida” (cinco días a dos semanas) del oral.

CORTICOSTEROIDES INHALADOS


� Los corticosteroides orales pueden ser útiles en el manejo de la inflamación asociada con el asma. Pueden

administrarse en dosis de “absorción rápida”, día de por medio o como régimen diario. Es probable que los

corticosteroides orales causen más efectos secundarios que los inhalados porque el torrente sanguíneo los

lleva a todas partes del cuerpo, mientras que los medicamentos inhalados van solamente a los pulmones.

� Los corticosteroides orales (generalizados) son usualmente recetados en “absorciones rápidas” de cinco días a

dos semanas para tratar episodios agudos de asma. Esta forma de usar los corticosteroides es el modo más

eficaz de reducir la inflamación y la frecuencia de episodios de asma futuros. Los corticosteroides orales es-

tán disponibles en tabletas o jarabe. En una situación de emergencia, el médico puede administrar corticos-

teroides por inyección o vía intravenosa. Algunos ejemplos incluyen Prednisone, Solu-Medrol, OraPred, o

Prelone.

� Las absorciones rápidas (5 días a 2 semanas) de corticosteroides orales o los usados una sola vez en la sala de

emergencia, tienen bajo potencial para efectos secundarios. Puede experimentarse de manera pasajera, lige-

ro aumento de peso o de apetito, irregularidades menstruales, cambios de humor o calambres musculares.

� Es importante terminar todo el tratamiento de corticosteroides orales que se le ha recetado. Cuando los

esteroides se usan en dosis de absorciones rápidas durante más o menos una semana, pueden suspenderse

abruptamente pero si se usan por más de una o dos semanas, la dosis debe reducirse gradualmente

(“disminución poco a poco”) de esa manera su cuerpo puede aumentar de nuevo la producción de esteroides

naturales. Los proveedores de cuidado de la salud deben proporcionar instrucciones específicas para dismi-

nuir la dosis poco a poco.

� Algunas veces, el asma difícil de manejar puede ser tratada solamente con el uso regular de corticosteroides

orales a diario o alternando los días. El uso de esteroides orales en esta forma, conlleva mucha más probabi-

lidad de efectos secundarios y el médico que los receta debe balancear el riesgo de los efectos contra el ries-

go del asma sin control. Algunos de los efectos secundarios posibles incluyen intolerancia a la glucosa (una

forma reversible de diabetes), úlcera péptica, distensión abdominal, aumento de peso, presión arterial alta,

osteoporosis, moretones, glaucoma y cataratas.

� Si es necesario el uso rutinario de un corticosteroide oral, su médico puede recomendar que reciba el medi-

camento en un horario de día de por medio. Si esto no logra llevar su asma bajo control, puede precisar un

horario diario. Generalmente, la dosis debe recibirse en la mañana antes de las 8 a.m. con un alimento para

imitar el ciclo natural del cuerpo en la producción de esteroide y minimizar los efectos secundarios.

� Si ha recibido corticosteroides orales durante el año anterior, debe informárselo a cualquier médico,

cirujano, anestesista o dentista quien le atiende para alguna otra afección.

CORTICOSTEROIDES ORALES (GENERALIZADOS)

Formulario de studio ACE #10: Tipos de medicamento, Página 4 de 6

� Los retardantes de leucotrieno, tales como Singulair®, son medicamentos para el asma que ayudan a reducir

y prevenir la inflamación que ocurre en las vías respiratorias de una persona con asma. Pertenecen al grupo

de medicamentos “controladores” del asma. En el asma y otras enfermedades en las cuales la inflamación

juega un papel, los químicos en el cuerpo llamados leucotrienos, se ligan a las células ocasionando la infla-

mación. Los retardantes de leucotrieno actúan bloqueando su ligación a las células para así reducir la infla-

mación en las vías respiratorias de una persona con asma.

� Los retardantes de leucotrieno no abren inmediatamente las vías respiratorias y por eso no deben usarse

para tratar episodios agudos de asma. Al igual que los corticosteroides inhalados, no ofrecen alivio pronto y

pueden dar la impresión de no tener efecto. No relajan los músculos tensos y es por eso que no siente rápi-

damente que puede respirar mejor . En cambio, obran lentamente para reducir la inflamación después de un

tiempo .

� Los retardantes de leucotrieno no son medicamentos antinflamatorios tan “poderosos” como los corticoste-

roides inhalados y no obran efectivamente en todo mundo. El valor principal es que tienen efectos antinfla-

matorios moderados, vienen en forma de píldora y solamente necesitan recibirse una vez al día.

� Los retardantes de leucotrieno son medicamentos generalmente muy seguros.

RETARDANTES DE LEUCOTRIENO

Formulario de estudio ACE #10: Tipos de medicamento,Página 5 de 6

� Advair® y Symbicort® son medicamentos inhalados que combinan dos tratamientos separados para el asma, un

corticosteroide inhalado y un agonista beta de acción prolongada dentro de un inhalador.

� El componente del corticosteroide reduce la inflamación en las vías respiratorias. Los corticosteroids inhalados son

muy diferentes de los esteroides anabólicos usados a veces ilegalmente por los atletas para aumentar la masa muscu-

lar. Los corticosteroides son medicamentos antinflamatorios muy efectivos. Para algunos pacientes, pueden ser sen-

cillamente el medicamento más eficaz en el tratamiento del asma de moderada a grave porque rompen el ciclo infla-

matorio y reducen la probabilidad de episodios futuros. El otro medicamento en Advair® o Symbicort® es un ago-

nista beta de acción prolongada que relaja las bandas musculares que rodean las vías respiratorias, permitiendo que

se abran. Al combinar estos dos medicamentos controladores en uno, Advair® o Symbicort® se tratan al mismo

tiempo la inflamación y la tensión de las vías respiratorias que van asociadas con el asma. Estos inhaladores vienen

en concentrados diferentes en los cuales varía la cantidad de corticosteroide.

� Advair® o Symbicort® se administran para la prevención de los síntomas del asma y no deben usarse para tratar

episodios agudos. Los síntomas de asma aguda deben tratarse con un agonista beta de acción temporal tal como

albuterol. Advair® o Symbicort® típicamente se administran dos veces al día, una vez en la mañana y una vez en la

noche. En dosis bajas, el cuerpo absorbe muy poco corticosteroide pero en dosis más altas, algo se absorbe.

� Los efectos secundarios de Advair® o Symbicort® son los mismos que aquellos de los corticosteroides inhalados y

de los agonistas beta de acción prolongada. Una proporción pequeña de pacientes que usan corticosteroids inhalados

experimenta efectos secundarios tales como:

� Estomatitis/muguet: infección de hongos en la boca, lengua o garganta (causa puntitos blancos)

� Ronquera (algunas veces)

� Aunque las dosis muy altas de corticosteroides inhalados tienen el potencial de causar algunos de los mismos efectos

secundarios que los corticosteroides orales, sus beneficios son mayores que cualquier efecto negativo. Para dismi-

nuir la posibilidad de experimentar efectos negativos, Advair® o Symbicort® deben recibirse en la concentración

más baja que eficazmente controle su asma .

� Los efectos secundarios posibles de agonistas beta incluyen ritmo cardíaco irregular o rápido, nerviosismo, temblo-

res musculares, insomnio, náusea y vómito. El uso excesivo de estos medicamentos puede producir aumento de

receptividad bronquial (esto es cuando las vías respiratorias que ya están “espásmicas” debido al asma, pueden po-

nerse aún más espasmódicas o más receptivas).

Advertencia: Si está usando Advair® o Symbicort® y desarrolla un episodio grave de asma que no responde a su

medicamento usual, es importante comunicarse de inmediato con un médico. El episodio grave de asma puede im-

pedirle inhalar los corticosteroides en sus pulmones y tal vez necesite un tratamiento con corticosteroides orales.

ADVAIR® Y SYMBICORT® (COMBINACIÓN DE INHALADORES)

Formulario de estudio ACE #10:Tipos de medicamento, Página 6 de 6

FORMULARIO #10: ¿CUÁNTO T IEMPO DURARÁ SU INHALADOR?

� Al comenzar a usar un inhalador nuevo y por primera vez, determine el tiempo que el frasco durará y fije la fecha en un calendario o en el

mismo frasco.

� Asegure de recibir un nuevo frasco al menos una semana antes de que se termine.

� Recuerde que estos medicamentos deben usarse a diario. Esto no funciona con los medicamentos de rescate que se usan según sus necesidades,

tal como el albuterol.

� Recuerde de enjuagarse la boca después de usar su inhalador para disminuir el riesgo de tener muguet o candidosis bucal .

Nombre del Medicamento

Dosis por inhalador

1111 2222 4444 6666 8888

QVAR 100 100 días 50 días 25 días 16 días 12 días

Flovent HFA 120 120 días 60 días 30 días N/A N/A

Pulmicort Flexhaler

120 120 días 60 días 30 días 20 días 15 días

Asmanex Twisthaler

120 120 días 60 días N/A N/A N/A

Advair HFA 120 120 días 60 días 30 días N/A N/A

Advair Diskus 60 60 días 30 días N/A N/A N/A

Symbicort 120 120 días 60 días 30 días N/A N/A

Formulario Estudio ACE #10: Tipos de Medicamentos, Página 7 de 7

Dosis Por Día

Formulario #11: ListA DE COTEJO PARA EL USO APROPIADO DEL INHALADOR

El paciente:

� ¿Quitó la tapa de la boquilla y agitó bien el inhalador antes de cada rociada?

� ¿Mantuvo el inhalador con la boquilla hacia abajo y exhaló por completo? � ¿Colocó la boquilla en la boca y cerró los labios alrededor de ella?

� ¿Pulsó la parte superior del frasco todo el camino al respirar lenta y profundamente por la boca?

� ¿Aguantó la respiración hasta por 10 segundos, y luego respiró normalmente?

� Si se usa un espaciador: ¿Tenía la boquilla del espaciador entre sus dientes con los labios cerrados alrededor durante la descarga?

Pregunte al paciente:

� Si usted estuviera realmente usando un inhalador, ¿cuánto tiempo esperaría antes de tomar una segunda bocanada? (Respuesta: 1

minuto o más)

El paciente:

� ¿Sostuvo el DISKUS en una mano y puso el pulgar de su otra mano en el hueco reservado para ello?

� ¿Empujó su pulgar tan lejos como podía hasta que la boquilla aparece y encaja en posición?

� ¿Sostuvo el DISKUS en una posición nivelada con la boquilla hacia él?

� ¿Deslizó la palanca lejos de el/ella tan lejos como pudo hasta que encajó?

� ¿Exhaló por completo mientras se mantenía el nivel del DISKUS y lejos de su boca?

� ¿Colocó la boquilla en sus labios e inhaló rápida y profundamente a través del DISKUS?

� ¿Retiró el DISKUS de su boca, mantuvo la respiración durante unos 10 segundos, o hasta lo más cómodo?

� ¿Exhaló lentamente después de contener la respiración?

� ¿Cerró el DISKUS deslizando el dedo pulgar hacia atrás en la medida posible hasta que quedó cerrada?

PULMICORT FLEXHALER®

El paciente:

� ¿Mantuvo el FLEXHALER en posición vertical en una mano y después giró la tapa y la levantó con la otra mano?

� ¿Usó su otra mano para sostener el inhalador en el centro y luego giró con agarre total en una dirección en la medida posible?

� ¿Giró totalmente de nuevo en la otra dirección hasta que se detuvo y se escuchó un clic?

� ¿Giró la cabeza lejos del inhalador y exhaló?

� ¿Colocó la boquilla en la boca, cerró los labios alrededor de ella, y respiró profundamente y con fuerza a través del inhalador?

� ¿Aguantó la respiración por 5-10 segundos después de la inhalación?

� ¿Exhaló lentamente, NO en la boquilla?

Pregunte al paciente:

� Si usted estuviera realmente usando un inhalador, ¿cuánto tiempo esperaría antes de tomar una segunda bocanada? (Respuesta: 30

segundos o más)

HFA (Albuterol / ICS)

Advair Diskus®

Asmanex Twisthaler®

El paciente:

� ¿Sostuvo el inhalador en posición vertical con la base coloreada en el fondo?

� ¿Mientras sostuvo la base, giró la tapa en sentido contrario para quitar la tapa?

� ¿Exhaló completamente?

� ¿Colocó la boquilla en la boca, manteniéndola en posición horizontal (de lado), cerró sus labios alrededor de ella, y tomó una respi-

ración rápida y profunda?

� ¿Retiró la TWISTHALER de la boca y aguantó la respiración durante unos 10 segundos, o hasta lo más cómodo?

� ¿Puso la tapa en el inhalador y giró en sentido horario, mientras presionaba suavemente hacia abajo hasta que oyó un click?

COMO UTILIZAR SU INHALADOr

1. Quite la tapa de la boquilla. 2. Agite bien el inhalador antes de cada rocío. 3. Sostenga el inhalador con la boquilla hacia abajo. Exhale por la boca, exhalando

completamente. Incline la cabeza ligeramente hacia atrás para enderezar las vías respiratorias de los pulmones.

4. Coloque la boquilla en la boca y cierre los labios alrededor de ella. 5. Sostenga el inhalador con el pulgar en la parte inferior y su dedo índice o me-

dio en la parte superior. Empuje la parte superior del frasco hasta el fon-do mientras usted respira lenta y profundamente por la boca.

6. Quite el dedo del frasco. Después de respirar en todo el camino, saque el inhala-dor de su boca y cierre la boca.

7. Aguante la respiración tanto tiempo como pueda, hasta 10 segundos. Esto per-mite que la medicina llegue profundamente a los pulmones. Luego respire nor-malmente.

8. Si se prescriben más rocíos, espere 1 minuto y luego agite el inhalador una vez más. Repita los pasos anteriores.

� Si usted usa un espaciador, coloque la boquilla entre los dientes y cierre los la-

bios alrededor del tubo. El uso de un espaciador es una buena idea porque ayuda a enviar el medicamento más profundamente en los pulmones.

� Si usted usa un inhalador de corticosteroides, enjuáguese la boca después de ca-da uso para evitar manchas blancas en la boca ("Estomatitis/muguet"). Con un separador puede reducir las probabilidades de desarrollar candidiasis bucal.

COMO UTILIZAR SU Advair diskus® INHALADOR DE POLVO SECO

1. Sostenga el DISKUS en una mano y ponga el pulgar de su otra mano en la apertura pa-ra esto.

2. Empuje su pulgar tan lejos de usted como pueda hasta que aparezca la boquilla y encaje en posición.

3. Sostenga el DISKUS en una posición nivelada y llana, con la boquilla en su dirección. 4. Deslice la palanca tan lejos de usted como pueda hasta que suene un “click”. El DISKUS

está ahora listo para usar. (Cada vez que la palanca es retraída, está lista una dosis para ser inhalada. Esto se muestra por una reducción en el número del contador de dosis. A este punto, evite liberar o desperdiciar dosis por error. No cierre el aparato. No juegue con la palanca. No mueva la palanca más de una vez.)

5. Antes de inhalar su dosis, exhale completamente mientras sostiene el DISKUS nivelado y lejos de su boca. Recuerde, nunca exhale en la boquilla.

6. Ponga la boquilla en sus labios. Inhale rápida y profundamente a través del DISKUS, no a través de su nariz.

7. Remueva el DISKUS de su boca. Contenga su respiración por unos 10 segundos, o tanto como le sea cómodo. Exhale lentamente.

8. Cuando termine, cierre el DISKUS. Coloque su pulgar en la apertura y deslícela hacia usted tanto como sea posible. El DISKUS cerrará con un “click”.

� La palanca regresará automáticamente a su posición original y se reactivará. El

DISKUS está listo ahora para tomar su próxima dosis. RECUERDE:

• Nunca exhale en el DISKUS. • Nunca intente desarmar el DISKUS. • Siempre active y utilice el DISKUS en una posición nivelada y horizontal. • Nunca lave la boquilla ni ninguna otra parte del DISKUS. MANTENGALO SECO. Siempre mantenga el DISKUS en un lugar seco.

COMO UTILIZAR SU Pulmicort Flexhaler®

Preparando su FLEXHALER 1. Sostenga el inhalador por el agarre de modo que la tapa apunte hacia arriba. Con la otra mano,

gire la tapa y levántela. 2. Mientras mantiene la FLEXHALER vertical, utilice la otra mano para sujetar el inhalador en el

medio (no en la parte superior de la boquilla). 3. Gire el control cuanto pueda totalmente en una dirección, luego de nuevo en la otra direc-

ción hasta que se detenga (no importa en qué dirección lo haga por primera vez). Se oye un "click" en uno de los movimientos de torsión.

4. Repita el paso 3. Su FLEXHALER está preparado y está listo para su primera dosis. Proveyendo una Dosis 1. Mantenga su FLEXHALER vertical. Con la otra mano, gire la tapa y levántela. 2. Use su otra mano para sostener el inhalador en el medio. No sostenga la boquilla cuando se carga

el inhalador. 3. Gire el control cuanto pueda totalmente en una dirección, luego de nuevo en la otra direc-

ción hasta que se detenga (no importa en qué dirección lo haga por primera vez). Se oye un "click" en uno de los movimientos de torsión.

4. No agite el inhalador después de cargarlo. Inhalando una Dosis 1. Gire la cabeza lejos del inhalador y exhale. 2. Coloque la boquilla en la boca y cierre los labios alrededor de ella. Respire profundamente y con

fuerza a través del inhalador. Aguante la respiración durante 10 segundos, o hasta donde le sea más cómodo.

3. Usted puede no sentir la presencia de cualquier medicamento entrando a sus pulmones. Esto no quiere decir que usted no recibió el medicamento y no debe repetir la inhalación.

4. No muerda ni presione la boquilla. 5. Retire el inhalador de la boca y exhale. No sople en la boquilla. 6. Si se prescribe más de una dosis , repita los pasos anteriores, después de esperar por lo menos

30 segundos. 7. Cuando haya terminado, coloque la tapa en el inhalador y cierre enroscando. 8. Enjuague su boca con agua después de cada dosis para disminuir el riesgo de contraer candidiasis

bucal. No trague el agua.

Como uTILIZar su asmanex twisthaler

1. Retire el TWISTHALER de su envase metálico y escriba la fecha en la etiqueta de la ta-pa. Deseche el inhalador 45 días después de esta fecha o cuando el contador lee "00", lo que ocurra primero.

2. Sostenga el inhalador en posición vertical con la base de color en la parte inferior. Es importante que usted retire la tapa mientras se está en esta posición para asegurarse de que usted reciba la cantidad correcta de medicamento con cada dosis.

3. Sosteniendo la base de color, gire la tapa en sentido contrario al horario para remover-la. Al levantar la tapa, el contador de dosis en la base hará un conteo regresivo por uno. El quitar la tapa carga el TWISTHALER con el medicamento.

4. Exhale completamente y a continuación, lleve el TWISTHALER hasta la boca con la bo-quilla hacia usted. Coloque la boquilla en su boca y tome una respiración rápida y pro-funda. Puede no ser capaz de probar, oler, o sentir el polvo fino después de la inhala-ción. Asegúrese de que no cubra la ventilación, mientras que mantiene la inhalación de la dosis.

5. Retire el TWISTHALER de la boca y aguante la respiración durante unos 10 segun-dos, o hasta lo más cómodo. No exhale en el inhalador.

6. Después de tomar el medicamento, limpie la boquilla en seco, si es necesario, vuelva a colocar la tapa cerrando con firmeza el TWISTHALER de inmediato.

7. Asegúrese de que la flecha está en línea con el contador de dosis. Ponga la tapa en el in-halador y gire hacia la derecha a medida que presiona suavemente hasta que oiga un “click” para hacerle saber que la tapa esté bien cerrada.

8. Repita los pasos 2-7 si otra dosis ha sido prescrita por su médico. 9. Enjuáguese la boca cada vez y después de usar su TWISTHALER.

La Flecha Endentada debe alinearse con el Contador de Dosis.

Reemplace la tapa y voltee a la derecha hasta oír un “click”.

Flecha Endentada Contador de Dosis

Escuchará un “click” que le hará saber que la tapa está completa-mente cerrada.

Esta es la única forma de estar seguro que su próxima dosis está descargada apropiada-mente.

Did the patient:

� Take the cap off the mouthpiece then shake the inhaler well before each spray?

� Hold the inhaler with the mouthpiece down and exhale fully?

� Put the mouthpiece in their mouth and close their lips around it?

� Push the top of the canister all the way down while breathing in deeply and slowly through their mouth?

� Hold their breath for up to 10 seconds, then breathe normally?

� If using a spacer: Have the mouthpiece of the spacer between their teeth with their lips closed around it during discharge?

Ask the patient:

� If you were really using an inhaler, how long would you wait before taking a second puff? (Answer: 1 or more minutes)

Did the patient:

� Hold the diskus in one hand and put the thumb of their other hand on the thumbgrip?

� Push their thumb away from them as far as it will go until the mouthpiece appears and snaps into position?

� Hold the diskus in a level position with the mouthpiece towards them?

� Slide the lever away from them as far as it will go until it clicks?

� Exhale fully while holding the diskus level and away from their mouth?

� Put the mouthpiece to their lips and inhale quickly and deeply through the diskus?

� Remove the diskus from their mouth, then hold their breath for about 10 seconds, or as long as comfortable?

� Exhale slowly after holding their breath?

� Close the diskus by sliding the thumbgrip back towards them as far as it will go until it clicks shut?

PULMICORT FLEXHALER®

Did the patient:

� Hold the flexhaler upright in one hand then twist the cover and lift it off with the other hand?

� Use their other hand to hold the inhaler in the middle then twist with grip fully in one direction as far as it will go?

� Twist it fully back again in the other direction as far as it will go until a click is heard?

� Turn their head away from the inhaler and exhale?

� Place the mouthpiece in their mouth, close their lips around it, then breathe in deeply and forcefully through the inhaler?

� Hold their breath for 5-10 seconds after inhalation?

� Exhale slowly, NOT into the mouthpiece?

Ask the patient:

� If you were really using a inhaler, how long would you wait before taking a second inhalation? (Answer: 30 seconds or more)

HFA (Albuterol / ICS)

Advair Diskus®

Asmanex Twisthaler®

Did the patient:

� Hold the inhaler upright with the colored base on the bottom?

� While holding the base, twist the cap in a counterclockwise direction to remove the cap?

� Breathe out fully?

� Place the mouthpiece in their mouth, holding it horizontally (on its side), close their lips around it, and take in a fast, deep breath?

� Remove the TWISTHALER from their mouth and hold their breath for about 10 seconds, or as long as comfortable?

� Put the cap back onto the inhaler and turn it in a clockwise direction while gently pressing down until a click is heard?

Form #11: Checklist for proper inhaler use

How to use your inhaler

1. Take the cap off the mouthpiece. 2. Shake the inhaler well before each spray. 3. Hold the inhaler with the mouthpiece down. Breath out through your mouth,

exhaling fully. Tilt your head back slightly to straighten the airways to your lungs.

4. Put the mouthpiece in your mouth and close your lips around it. 5. Hold the inhaler with your thumb on the bottom and your index or middle fin-

ger on top. Push the top of the canister all the way down while you breathe in deeply and slowly through your mouth.

6. Take your finger off the canister. After breathing in all the way, take the inhaler out of your mouth and close your mouth.

7. Hold your breath as long as you can, up to 10 seconds. This allows the medicine to reach deeply into your lungs. Then breathe normally.

8. If more sprays are prescribed, wait 1 minute then shake the inhaler again. Re-peat steps above.

� If you use a spacer, put the mouthpiece between your teeth and seal your lips

around the tube. Using a spacer is a good idea because it helps to get the medi-cine deeper into your lungs.

� If you use a corticosteroid inhaler, rinse your mouth out after use to prevent white spots in the mouth ( “thrush”). Using a spacer can lessen the chances of getting thrush.

How to use your Advair diskus® Dry powder inhaler

1. Hold the DISKUS in one hand and put the thumb of your other hand on the thumbgrip.

2. Push your thumb away from you as far as it will go until the mouthpiece appears and snaps into position.

3. Hold the DISKUS in a level, flat position with the mouthpiece towards you. 4. Slide the lever away from you as far as it will go until it clicks. The DISKUS is now

ready to use. (Every time the lever is pushed back, a dose is ready to be inhaled. This is shown by a decrease in numbers on the dose counter. At this point, avoid releasing or wasting doses by mistake. Do not close the device. Do not play with the lever. Do not advance the lever more than once.)

5. Before inhaling your dose, breathe out (exhale) fully while holding the DISKUS level and away from your mouth. Remember, never breathe out into the mouthpiece.

6. Put the mouthpiece to your lips. Breathe in quickly and deeply through the DISKUS, not through your nose.

7. Remove the DISKUS from your mouth. Hold your breath for about 10 seconds, or as long as comfortable. Breathe out slowly.

8. When you are finished, close the DISKUS. Put your thumb on the thumbgrip and slide the thumbgrip back towards you as far as it will go. The DISKUS will click shut.

� The lever will automatically return to its original position and will reset. The DISKUS

is now ready for you to take your next scheduled dose. REMEMBER:

• Never exhale into the DISKUS. • Never attempt to take the DISKUS apart. • Always activate and use the DISKUS in a level, horizontal position. • Never wash the mouthpiece or any part of the DISKUS. KEEP IT DRY. • Always keep the DISKUS in a dry place.

How to use your Pulmicort Flexhaler®

Priming Your FLEXHALER 1. Hold the inhaler by the grip so that the cover points upward. With your other hand, turn the cov-

er and lift it off. 2. While holding the FLEXHALER upright, use your other hand to hold the inhaler in the middle

(not at the top of the mouthpiece). 3. Twist the grip as far as it will go in one direction then fully back again in the other direction until

it stops (it does not matter which way your turn it first). You will hear a “click” during one of the twisting movements.

4. Repeat Step 3. Your FLEXHALER is now primed and you are ready for your first dose. Loading a Dose 1. Hold your FLEXHALER upright. With your other hand, twist the cover and lift it off. 2. Use your other hand to hold the inhaler in the middle. Do not hold the mouthpiece when you

load the inhaler. 3. Twist the grip fully in one direction as far as it will go. Twist it fully back again in the other direc-

tion as far as it will go (it does not matter which way you turn it first). You will hear a “click” dur-ing one of the twisting movements.

4. Do not shake the inhaler after loading it. Inhaling a Dose 1. Turn your head away from the inhaler and breathe out (exhale). 2. Place the mouthpiece in your mouth and close your lips around it. Breathe in deeply and forceful-

ly through the inhaler. Hold your breath for 10 seconds, or as long as comfortable. 3. You may not sense the presence of any medication entering your lungs. This does not mean that

you did not get the medication and you should not repeat your inhalation. 4. Do not chew or bite on the mouthpiece. 5. Remove the inhaler from your mouth and exhale. Do not blow out into the mouthpiece. 6. If more than once dose is prescribed, repeat the steps above after waiting at least 30 seconds. 7. When you are finished, place the cover back on the inhaler and twist it shut. 8. Rinse your mouth with water after each dose to decrease your risk of getting thrust. Do not

swallow the water.

How to use your asmanex twisthaler

1. Remove the TWISTHALER from its foil pouch and write the date on the cap label. Throw away the inhaler 45 days after this date or when the counter reads “00,” which-ever comes first.

2. Hold the inhaler straight up with the colored base on the bottom. It is important you remove the cap while it is in this position to make sure you get the right amount of medicine with each dose.

3. Holding the colored base, twist the cap in a counterclockwise direction to remove it. As you lift off the cap, the dose counter on the base will count down by one. Remov-ing the cap loads the TWISTHALER with the medicine.

4. Breathe out fully then bring the TWISTHALER up to your mouth with the mouthpiece facing towards you. Place the mouthpiece in your mouth and take in a fast, deep breath. You may not be able to taste, smell, or feel the fine powder after inhaling it. Be sure to not cover the ventilation holds while inhaling the dose.

5. Remove the TWISTHALER from your mouth and hold your breath for about 10 se-conds, or as long as comfortable. Do not breathe out (exhale) into the inhaler.

6. After taking your medicine, wipe the mouthpiece dry if needed then replace the cap by firmly closing the TWISTHALER right away.

7. Be sure the arrow is in line with the dose counter. Put the cap back onto the inhaler and turn it clockwise as you gently press down until you hear a click to let you know the cap is fully closed.

8. Repeat Steps 2-7 if another dose is has been prescribed by your provider. 9. Rinse your mouth each and every time after using your TWISTHALER.

Formulario 12: El Diario de Asma de ________

Fecha Silbido Tos Actividad Dormir 1 2 3 4 5 AM PM Otro

Desencadenantes/

Comentarios

Síntomas de asma

Mis Medicamentos

Los números

diarios de mi

flujo máximo

Mi Mejor Flujo Máximo = ________

Verde: Sobre ______

Amarillo: Entre _____ y ______

Rojo: Bajo ______

Silbido Tos Actividad Dormir

Nada = 0 Nada = 0 Normal = 0 Duermo bien = 0

Ocasional = 1 Ocasional = 1 Puedes ser activo por un rato antes que empiecen los síntomas = 1 Duermo bien un tos o silbido pequeño = 1

Frecuente = 2 Frecuente = 2 Solo puedes caminar = 2 Me desperté entre 2-4 veces con tos o silbido = 2

Continua = 3 Continua =3 Has faltado la escuela o has quedado adentro = 3 Me estaba despertado mucha de la noche

con síntomas de asma = 3

60%

80%

80%

60% Pon un cheque cada vez que lo tomas.

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For use with patients 2-4 years old - Asthma Action Plan

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